AIDS Care, 2015 Vol. 27, No. 6, 688–692, http://dx.doi.org/10.1080/09540121.2015.1005004
Factors associated with establishment-based female sex workers accessing health care services in Shanghai Rong Pana,b,c, Limin Maod*, Na Hea,b, Jing Zhangc, Kun Chenc, Cuiqin Liaoc, Xian Tangc, Xiangzhen Gongc, Megan Blaxlande and John de Witd a
Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; bChinese Ministry of Education’s Key Laboratory of Public Health Safety, Fudan University, Shanghai, China; cHongkou District Center for Disease Prevention and Control, Hongkou District, Shanghai, China; dCentre for Social Research in Health, UNSW Australia, Sydney, Australia; eSocial Policy Research Centre, UNSW Australia, Sydney, Australia (Received 28 September 2014; accepted 23 December 2014) Female sex workers are a priority population for HIV prevention and health promotion in China. This paper examines the patterns of and factors associated with the utilisation of HIV-related and general health services by establishmentbased sex workers in Hongkou District, Shanghai. Participants were recruited through a three-stage sampling strategy and invited to self-complete a brief survey in 2012. The median age of the 400 participants included in the analyses was 33 years (range = 18–52 years old), with over three-quarters being married at the time of the survey. Participants were mostly internal migrants, more than half had lived in Shanghai for six months or longer and nearly two-thirds were working in an establishment with a total of less than five female sex workers. Routine physical examination and HIV testing were the most commonly accessed health services in the previous 12 months. Altogether, 347 women (86.8%) had actively sought, including 157 women had obtained, free health services mainly from local Community Health Service Centres (CHSCs) in the previous 12 months. The active seeking of free, largely CHSC-provided health services was associated with a longer duration of residence in Shanghai (adjusted odds ratio [AOR] = 2.55, 95% CI = 1.32–4.93; p < 0.01) and having tested for HIV in the previous 12 months (AOR = 3.68, 95% CI = 1.84–7.38; p < 0.001). Conversely, a higher annual income (AOR = 0.41, 95% CI = 0.21–0.80; p < 0.01), working in a larger establishment (AOR = 0.40, 95% CI = 0.20–0.79; p < 0.01) and knowing that HIV can be transmitted through blood transfusion with unscreened blood (AOR = 0.21, 95% CI = 0.05–0.91; p < 0.05) were associated with not actively seeking such services. Free, community-based health services are highly demanded by establishment-based female sex workers in Shanghai. Scaling-up of free and integrated health services provided by community-based health service providers in metropolitan areas in China and beyond holds promise for promoting health and well-being of female sex workers. Keywords: female sex workers; migration; HIV testing; community-based health service
Introduction Of HIV notifications among women at reproductive age in China, more than 20% have been attributed to sex work (Baral et al., 2012). With over 10 million female sex workers in China (Hong et al., 2012), several factors have fuelled HIV transmission in this key population. These include rapid social changes leading to a substantial increase in rural-to-urban (internal) migration that coincided with a resurgence of the sex industry (Poon, Li, Wong, & Hong, 2011; Yang et al., 2004), inadequate condom use between female sex workers and their sex partners (Lau et al., 2012) and low rates of testing for HIV and other sexually transmitted infections (Hong et al., 2012). Globally, fear of stigma and discrimination, especially by health service workers, and limited service affordability contribute to female sex workers’ underutilisation of HIV-related and general health services
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
(Ghimire, Smith, & van Teijlingen, 2011; Gomez et al., 2010; King & Maman, 2013; Ngo et al., 2007). In China, there are two additional barriers. First, free HIV testing is available only through a limited number of governmentdesignated providers, mostly within the Chinese Centers for Disease Control and Prevention system. Second, because of the illegality and high mobility of sex work, female sex workers, particularly those who are rural-tourban migrants, often do not fully benefit from any government-subsidised health insurance schemes (Hong et al., 2012). Although female sex workers are a priority population for HIV prevention in China, limited research has been undertaken to date examining the patterns of and factors associated with their utilisation of HIV-related and general health services. The present study aims to address this important knowledge gap and was commissioned by the Centres for Disease Control and
AIDS Care Prevention in Hongkou District (hereafter referred to as local CDC), which has been the main provider of free HIV testing service locally and is one of the largest district-level CDCs in Shanghai. By 2012, four local Community Heath Service Centres (CHSCs) were also offering free HIV testing.
Methods The survey was conducted between May and July 2012. Ethics approval was obtained from the local CDC. In order to include a diverse sample, a three-stage sampling approach was adopted. Initially, two administrative subdivisions of the district, out of a total of eight, were randomly selected, after which 98 well-known entertainment sites were identified in these subdivisions. The study team then made initial contact with 505 eligible participants through time-location sampling. Female sex workers were invited to self-complete a questionnaire, with on-site support available. Upon completion of the survey they received a token of appreciation for their participation, valued at RMB 20 (USD3). The self-completion questionnaire assessed key sociodemographic characteristics, information regarding women’s work setting, and various HIV-related topics, including HIV knowledge and condom use with clients as well as with their spouse. Participants were also asked to indicate their use of the following health services in the 12 months prior to survey: face-to-face health promotion, routine physical examination (i.e., general health checkup), preventative vaccination, any general medical (e.g., diagnostic, therapeutic) interventions and testing for HIV. The questionnaire also assessed factors that may influence health service access: health insurance coverage, annual health-related expenditure, perceived financial difficulties in paying for out-of-pocket health services and distance to the nearest health service facility. To assess their free health service utilisation, participants were asked if they had actively sought or received mainly free health services, including free HIV testing, in the previous 12 months. They were further asked to indicate their most common (i.e., primary) type of health service provider (e.g., local CHSCs, local CDC). A dichotomous outcome variable was computed to capture if participants in the previous 12 months had actively sought mainly free health services from local CHSCs. As indicated by data presented below, local CHSCs were the most common provider of free health services. A multivariable logistic regression analysis, with a forward stepwise elimination process, was conducted to identify factors independently associated with free service access. All statistical analyses were performed using SPSS version 21.
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Results A total of 429 women provided verbal consent and commenced the questionnaire (response rate = 84.9%). The reported analyses are limited to the 400 respondents who provided complete data. As shown in Table 1, participants’ median age was 33 years, about one-third had no high school education and over three-quarters were married at the time of survey. All but six women were internal migrants (i.e., not originally born in Shanghai), with more than half having lived in Shanghai for six months or longer. Nearly two-thirds of participants worked in smaller-sized establishments (defined as less than five female sex workers per establishment). Women undertook a median of 10 hours of sex work per day and their median annual income was RMB 50,000 (USD8000). The majority of participants correctly identified all six HIV transmission routes (median knowledge summary score = 6). In the 12 months prior to the survey, participants were much more likely to report any condom use with their clients than with their spouse (Table 1). Table 1 shows that routine physical examination was the most commonly obtained health service in the previous 12 months (59.0%), followed by HIV testing (44.8%). Of the 186 participants (46.5%) who had received mainly free services, the majority (n = 157) selected local CHSCs as their primary free health service provider. While close to one-third of participants was entitled to the rural health insurance scheme, about 60% of participants had no health insurance. In the previous 12 months, just over 40% had paid at least RMB 500 (i.e., 10% of their average annual income) to obtain health services. Of these women, over 70% (n = 123; 30.8% of all 400 participants) reported a medium or high level of financial stress. Over one-third lived 1 km or more away from the nearest health care facility (Table 1). As shown in Table 2, in the previous 12 months, 347 women (86.8%) had actively sought, including 157 women had obtained, free health services mainly from local CHSCs. Having actively sought free health services mainly from local CHSCs was significantly associated with a longer duration of residence in Shanghai (adjusted odds ratio [AOR] = 2.55, 95% CI = 1.32–4.93; p < 0.01) and having tested for HIV in the previous 12 months (AOR = 3.68, 95% CI = 1.84–7.38; p < 0.001). Con‐ versely, having not actively sought free services mainly provided by local CHSCs was associated with a higher annual income (AOR = 0.41, 95% CI = 0.21–0.80; p < 0.01), working in a larger establishment with five or more female sex workers (AOR = 0.40, 95% CI = 0.20– 0.79; p < 0.01) and correctly identifying that HIV can be transmitted through blood transfusion with unscreened blood (AOR = 0.21, 95% CI = 0.05–0.91; p < 0.05; Table 2).
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Table 1. Main characteristics of a sample of establishment-based female sex workers in China (n = 400).
Socio-demographic characteristics Age
Marital status
Birthplace outside Shanghai Highest educational attainment
Duration of residence in Shanghai
18–20 years old 21–40 years old 41–52 years old Single/never married Divorced/widowed Currently married Up to primary school education Junior high school education Senior high school, vocational education or above
Factors associated with establishment-based female sex workers accessing health care services in Shanghai Rong Pana,b,c, Limin Maod*, Na Hea,b, Jing Zhangc, Kun Chenc, Cuiqin Liaoc, Xian Tangc, Xiangzhen Gongc, Megan Blaxlande and John de Witd a
Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China; bChinese Ministry of Education’s Key Laboratory of Public Health Safety, Fudan University, Shanghai, China; cHongkou District Center for Disease Prevention and Control, Hongkou District, Shanghai, China; dCentre for Social Research in Health, UNSW Australia, Sydney, Australia; eSocial Policy Research Centre, UNSW Australia, Sydney, Australia (Received 28 September 2014; accepted 23 December 2014) Female sex workers are a priority population for HIV prevention and health promotion in China. This paper examines the patterns of and factors associated with the utilisation of HIV-related and general health services by establishmentbased sex workers in Hongkou District, Shanghai. Participants were recruited through a three-stage sampling strategy and invited to self-complete a brief survey in 2012. The median age of the 400 participants included in the analyses was 33 years (range = 18–52 years old), with over three-quarters being married at the time of the survey. Participants were mostly internal migrants, more than half had lived in Shanghai for six months or longer and nearly two-thirds were working in an establishment with a total of less than five female sex workers. Routine physical examination and HIV testing were the most commonly accessed health services in the previous 12 months. Altogether, 347 women (86.8%) had actively sought, including 157 women had obtained, free health services mainly from local Community Health Service Centres (CHSCs) in the previous 12 months. The active seeking of free, largely CHSC-provided health services was associated with a longer duration of residence in Shanghai (adjusted odds ratio [AOR] = 2.55, 95% CI = 1.32–4.93; p < 0.01) and having tested for HIV in the previous 12 months (AOR = 3.68, 95% CI = 1.84–7.38; p < 0.001). Conversely, a higher annual income (AOR = 0.41, 95% CI = 0.21–0.80; p < 0.01), working in a larger establishment (AOR = 0.40, 95% CI = 0.20–0.79; p < 0.01) and knowing that HIV can be transmitted through blood transfusion with unscreened blood (AOR = 0.21, 95% CI = 0.05–0.91; p < 0.05) were associated with not actively seeking such services. Free, community-based health services are highly demanded by establishment-based female sex workers in Shanghai. Scaling-up of free and integrated health services provided by community-based health service providers in metropolitan areas in China and beyond holds promise for promoting health and well-being of female sex workers. Keywords: female sex workers; migration; HIV testing; community-based health service
Introduction Of HIV notifications among women at reproductive age in China, more than 20% have been attributed to sex work (Baral et al., 2012). With over 10 million female sex workers in China (Hong et al., 2012), several factors have fuelled HIV transmission in this key population. These include rapid social changes leading to a substantial increase in rural-to-urban (internal) migration that coincided with a resurgence of the sex industry (Poon, Li, Wong, & Hong, 2011; Yang et al., 2004), inadequate condom use between female sex workers and their sex partners (Lau et al., 2012) and low rates of testing for HIV and other sexually transmitted infections (Hong et al., 2012). Globally, fear of stigma and discrimination, especially by health service workers, and limited service affordability contribute to female sex workers’ underutilisation of HIV-related and general health services
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
(Ghimire, Smith, & van Teijlingen, 2011; Gomez et al., 2010; King & Maman, 2013; Ngo et al., 2007). In China, there are two additional barriers. First, free HIV testing is available only through a limited number of governmentdesignated providers, mostly within the Chinese Centers for Disease Control and Prevention system. Second, because of the illegality and high mobility of sex work, female sex workers, particularly those who are rural-tourban migrants, often do not fully benefit from any government-subsidised health insurance schemes (Hong et al., 2012). Although female sex workers are a priority population for HIV prevention in China, limited research has been undertaken to date examining the patterns of and factors associated with their utilisation of HIV-related and general health services. The present study aims to address this important knowledge gap and was commissioned by the Centres for Disease Control and
AIDS Care Prevention in Hongkou District (hereafter referred to as local CDC), which has been the main provider of free HIV testing service locally and is one of the largest district-level CDCs in Shanghai. By 2012, four local Community Heath Service Centres (CHSCs) were also offering free HIV testing.
Methods The survey was conducted between May and July 2012. Ethics approval was obtained from the local CDC. In order to include a diverse sample, a three-stage sampling approach was adopted. Initially, two administrative subdivisions of the district, out of a total of eight, were randomly selected, after which 98 well-known entertainment sites were identified in these subdivisions. The study team then made initial contact with 505 eligible participants through time-location sampling. Female sex workers were invited to self-complete a questionnaire, with on-site support available. Upon completion of the survey they received a token of appreciation for their participation, valued at RMB 20 (USD3). The self-completion questionnaire assessed key sociodemographic characteristics, information regarding women’s work setting, and various HIV-related topics, including HIV knowledge and condom use with clients as well as with their spouse. Participants were also asked to indicate their use of the following health services in the 12 months prior to survey: face-to-face health promotion, routine physical examination (i.e., general health checkup), preventative vaccination, any general medical (e.g., diagnostic, therapeutic) interventions and testing for HIV. The questionnaire also assessed factors that may influence health service access: health insurance coverage, annual health-related expenditure, perceived financial difficulties in paying for out-of-pocket health services and distance to the nearest health service facility. To assess their free health service utilisation, participants were asked if they had actively sought or received mainly free health services, including free HIV testing, in the previous 12 months. They were further asked to indicate their most common (i.e., primary) type of health service provider (e.g., local CHSCs, local CDC). A dichotomous outcome variable was computed to capture if participants in the previous 12 months had actively sought mainly free health services from local CHSCs. As indicated by data presented below, local CHSCs were the most common provider of free health services. A multivariable logistic regression analysis, with a forward stepwise elimination process, was conducted to identify factors independently associated with free service access. All statistical analyses were performed using SPSS version 21.
689
Results A total of 429 women provided verbal consent and commenced the questionnaire (response rate = 84.9%). The reported analyses are limited to the 400 respondents who provided complete data. As shown in Table 1, participants’ median age was 33 years, about one-third had no high school education and over three-quarters were married at the time of survey. All but six women were internal migrants (i.e., not originally born in Shanghai), with more than half having lived in Shanghai for six months or longer. Nearly two-thirds of participants worked in smaller-sized establishments (defined as less than five female sex workers per establishment). Women undertook a median of 10 hours of sex work per day and their median annual income was RMB 50,000 (USD8000). The majority of participants correctly identified all six HIV transmission routes (median knowledge summary score = 6). In the 12 months prior to the survey, participants were much more likely to report any condom use with their clients than with their spouse (Table 1). Table 1 shows that routine physical examination was the most commonly obtained health service in the previous 12 months (59.0%), followed by HIV testing (44.8%). Of the 186 participants (46.5%) who had received mainly free services, the majority (n = 157) selected local CHSCs as their primary free health service provider. While close to one-third of participants was entitled to the rural health insurance scheme, about 60% of participants had no health insurance. In the previous 12 months, just over 40% had paid at least RMB 500 (i.e., 10% of their average annual income) to obtain health services. Of these women, over 70% (n = 123; 30.8% of all 400 participants) reported a medium or high level of financial stress. Over one-third lived 1 km or more away from the nearest health care facility (Table 1). As shown in Table 2, in the previous 12 months, 347 women (86.8%) had actively sought, including 157 women had obtained, free health services mainly from local CHSCs. Having actively sought free health services mainly from local CHSCs was significantly associated with a longer duration of residence in Shanghai (adjusted odds ratio [AOR] = 2.55, 95% CI = 1.32–4.93; p < 0.01) and having tested for HIV in the previous 12 months (AOR = 3.68, 95% CI = 1.84–7.38; p < 0.001). Con‐ versely, having not actively sought free services mainly provided by local CHSCs was associated with a higher annual income (AOR = 0.41, 95% CI = 0.21–0.80; p < 0.01), working in a larger establishment with five or more female sex workers (AOR = 0.40, 95% CI = 0.20– 0.79; p < 0.01) and correctly identifying that HIV can be transmitted through blood transfusion with unscreened blood (AOR = 0.21, 95% CI = 0.05–0.91; p < 0.05; Table 2).
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R. Pan et al.
Table 1. Main characteristics of a sample of establishment-based female sex workers in China (n = 400).
Socio-demographic characteristics Age
Marital status
Birthplace outside Shanghai Highest educational attainment
Duration of residence in Shanghai
18–20 years old 21–40 years old 41–52 years old Single/never married Divorced/widowed Currently married Up to primary school education Junior high school education Senior high school, vocational education or above
