Post-Gender-Based Violence Services Utilization Among Female Entertainment Workers in Cambodia: A Cross-Sectional Study
Abstract
Little is known about service utilization among female entertainment workers (FEWs) after experiencing gender-based violence (GBV). This study explored factors associated with post-GBV service utilization among FEWs in Cambodia. We included 299 FEWs, who experienced any forms of GBV in the past 12 months. This study highlights low access (14.05%) to post-GBV services among FEWs. Factors associated with post-GBV services utilization were marital status, living conditions, mental health, and types of entertainment venues. To improve post-GBV services utilization, ensuring quality, and availability of services are required. Further research is needed to develop pathways toward a supportive environment for FEWs to access these services.
Introduction
Female entertainment workers (FEWs) commonly experience stigma and discrimination resulting in behavioral risks and poor mental health. In Cambodia, FEWs work in entertainment venues such as karaoke bars, massage parlors, restaurants, or beer gardens (Australian People for Health Education and Development Abroad, 2011). Since the implementation of the “Law on Suppression of Human Trafficking and Sexual Exploitation” in 2008 in Cambodia (Pearshouse, 2008), female sex workers (FSWs) have moved into indirect sex work based in entertainment venues. Therefore, FSWs have been classified under the umbrella of FEWs in the national HIV program (Australian People for Health Education and Development Abroad, 2011). Unlike FSWs, FEWs may or may not involve in sex work. In a recent survey among Cambodian FEWs recruited from the capital city and three other provinces, only 36% of the study participants reported selling sex in the past 3 months (Brody et al., 2019). It is important to note that there is a lack of literature on FEWs in other countries; therefore, published papers cited in this article outside the Cambodian context are the cases of FSWs. Being identified as entertainment workers instead of sex workers allows them to work at entertainment venues, where they may continue to engage in transactional sex. FEW populations have been growing, with an estimated number of 40,000 in 2014 (The United Nations Population Fund, 2015) to 70,000 in 2019 (Oxfam Cambodia, 2019).
Most of these entertainment venues are predominately alcohol-based workplaces, and FEWs are required to drink (Brody et al., 2020). In 2014, the Ministry of Labor and Vocational Training in Cambodia extended the occupational safety laws to include regulations to protect against occupational risks encountered by FEWs (Hsu et al., 2016). The risks addressed by the regulations include forcing FEWs to work overtime, drink alcohol, use drugs, or undergo abortions. There has been some progress in improving the occupation safety and health; however, challenges remain in implementing these regulations, including the limited number of labor inspectors to monitor the entertainment establishment throughout Cambodia (Hsu et al., 2016). A study found that 83.4% of Cambodian FEWs reported binge drinking, defined as having more than five alcoholic drinks on one day or night in the past 3 months (Lee et al., 2019). In a national survey, 53.0% of FEWs reported engaging in transactional sex, defined as having sexual intercourse in exchange for money or gifts in the past 12 months (Tuot et al., 2021). This situation may put FEWs at higher risk of contracting human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). The HIV prevalence among FEWs was 3.2% in 2016 compared to 0.6% among the Cambodian general population aged 15–49 years in the same year (Mun et al., 2017). The incidences of STIs among FEWs such as C. trachomatis, N. gonorrhea, and human papillomavirus (HPV) were 11.5%, 7.8%, and 41.1%, respectively (Couture et al., 2011, 2012).
Besides, FEWs are disproportionately affected by gender-based violence (GBV). GBV is defined as violence acted directly or indirectly against a person due to their gender, and it includes any experiences of physical, emotional, sexual, and substance abuse (UNHCR, 2020). In Cambodia, a study found that 60.5% of FEWs experienced GBV in their lifetime, of whom 37.5% experienced GBV in the past 6 months (Wieten et al., 2020). Similarly, 48.0% of women who engaged in sex work in Phnom Penh experienced physical or sexual violence in the preceding 12 months (Draughon Moret et al., 2016). GBV has a detrimental consequence on individuals’ sexual, physical, reproductive, and mental health, resulting in higher morbidity and mortality rates (Butchart & Mikton, 2014). For instance, a review study found that violence against sex workers not only increased HIV risk but also undermined the effectiveness of HIV intervention (Decker et al., 2015). Similarly, a study among FSWs in Kenya found that those with severe GBV experience had higher depressive symptoms, alcohol use disorders, and more sexual partners than those with low GBV (Roberts et al., 2018).
In addition to GBV, FEWs also face social stigma and poverty, which predispose them to mental health problems. A study in Cambodia found that 43.2% of FEWs had high levels of psychological distress (Brody et al., 2016). Similarly, a review on mental health problems among FSWs in low- and middle-income countries found the high pooled prevalence of depression (41.8%), anxiety (21.0%), post-traumatic stress disorder (19.7%), psychological distress (40.8%), recent suicide ideation (22.8%), and recent suicide attempts (6.3%) (Beattie et al., 2020). This prevalence might be higher among FEWs and FSWs who experienced GBV. Consequently, it is crucial that FEWs have access to quality post-GBV services.
As an HIV key population in the country, FEWs are eligible to receive free HIV, sexual and reproductive health, and GBV services provided by community-based non-governmental organizations (NGOs). However, since the passing of Cambodia's Law on the Suppression of Human Trafficking and Sexual Exploitation in 2008 (Pearshouse, 2008), brothels and sex work have been criminalized. Therefore, engagement in transactional sex among FEWs may reduce the likelihood of GBV disclosure, support service seeking, and service utilization. For instance, a qualitative study among Cambodian women, who engage in transactional sex in the past 3 months, found that the enforcement of this law reduced their access to health and medical services such as HIV testing and treatment (Maher et al., 2015). Similarly, a study among Cambodian police and HIV key populations, including FEWs, found that the key populations feared accessing harm reduction and health services (Schneiders & Weissman, 2016). The study also highlighted the negative attitudes of police toward key populations and vice versa (Schneiders & Weissman, 2016), which might be a barrier for key populations to access the services when needed. In addition to the illegality of sex work in Cambodia, those who engaged in sex work could be highly stigmatized; therefore, many may feel that they would be judged by the service providers (Muth et al., 2017). Likewise, a negative attitude among healthcare providers was one of the main barriers to STIs service use among FSWs in Laos (Phrasisombath et al., 2012). The current coronavirus disease 2019 (COVID-19) pandemic has created extra hardship for FSWs who have already experienced difficulties in maintaining their livelihoods (Shareck et al., 2021). A study among FSWs in Singapore suggested that the COVID-19 pandemic has resulted in greater insecurity in food and housing and reduced access to medical services (Tan et al., 2021).
Access to quality health services for those who experienced GBV, such as screenings, treatment, and linkages to clinical, legal, and social services, is essential from human rights and epidemiological perspectives. Screenings for GBV experiences are often not included as a part of general or sexual and reproductive health services. Additionally, many individuals may not disclose their GBV experiences to their providers for various reasons (O’Campo et al., 2011; Waalen et al., 2000). Those characterized as HIV key populations, such as FEWs, may even be less likely to disclose their GBV experiences. Besides, even if individuals reveal their experiences, they may not receive appropriate or adequate services or referrals according to the provider and the availability of services, especially in low-resource settings (Colombini et al., 2008; O’Doherty et al., 2014). With all these barriers, those engaged in transactional and commercial sex may be less likely to seek assistance because of stigmatization and discrimination at the health facilities (Hong et al., 2010; Miller et al., 2010).
Understanding the pathways that contribute to timely service uptake by FEWs can be challenging due to a wide range of barriers. A study in Kenya reported that FSWs found sexual and reproductive health commodities and services were often low and context-specific (Lafort et al., 2017). For instance, 34.4% of FSWs in Mombasa, Kenya, sought medical care after forced sex, while 51.9% of FSWs in Mysore, India, sought post-forced-sex medical care (Lafort et al., 2017). No previous studies have been conducted to examine the factors associated with post-GBV services utilization among Cambodian FEWs. Therefore, this study aimed to explore post-GBV services utilization and its associated factors among FEWs in Cambodia.
Methods
Study Design and Participants
This survey was conducted among FEWs in Phnom Penh, Banteay Meanchey, Battambang, Kampong Cham, Preah Sihanouk, Pursat, and Siem Reap provinces in October 2017. We included women in the study if they: (a) were at least 18 years old, (b) self-identified as an entertainment worker, including female sex workers, (c) were able to communicate in Khmer, the Cambodian national language, (d) were able and agreed to provide informed consent to participate in the study, and (e) had lived in the current city within the seven study sites for at least 3 months.
Sample Size and Sampling Procedures
In 2017, approximately 20,182 FEWs were under the coverage areas of KHANA, a leading NGO providing HIV and sexual and reproductive health services to key populations in Cambodia. Since the anticipated percentage frequency was unknown, we used 50% for the sample size calculation to prevent the underestimated prevalence. According to a 95% confidence level with a 5% margin of error and a design effect of 1.5, the minimum required sample size was 652, with 10% adjusted for the incomplete response, missing data, and rejection rate.
Figure 1 shows the flow chart of how the final sample came about. In brief, we obtained lists of entertainment venues and hotspots in the seven sites from KHANA's teams. We used a two-stage cluster method to select the entertainment venues from 803 venues and a simple random sampling method to select FEWs from 19,880 FEWs in the study sites. We then selected 10% of the total venues in each study site randomly. When the study sites with less than 10 venues were selected, 10 venues were applied, resulting in 102 adjusted venues with 2,314 FEWs. We randomly selected seven FEWs from each venue and included all FEWs if the venues had seven or fewer FEWs. The final sample in the analysis was 299.
Data Collection Training and Procedures
We formed three data collection teams; each team comprised a supervisor and four interviewers. The data collectors received 3 days of training that covered confidentiality, privacy, and interview techniques. We excluded FEWs who participated in the pre-test from the main study. FEWs were randomly selected from a name list of FEWs obtained from outreach workers. The data collectors contacted and screened the selected FEWs for eligibility with a screening tool and made an appointment with them for a face-to-face interview. We obtained written informed consent from each participant before the interview started.
Tool Development
A structured questionnaire was developed according to the existing tools adapted from previous studies. The questionnaire was first developed in English and then translated into Khmer. The Khmer version was back-translated into English to ensure the contents and meaning of the English version were retained. The questionnaire captured information on sociodemographic characteristics, various forms of GBV, post-GBV services utilization, perceived service quality, and mental health. We conducted a tool pre-test with nine FEWs at one entertainment venue in Phnom Penh and refined the questionnaire in a reflection meeting.
Measurements
GBV experiences included physical, emotional, sexual, and substance abuse (UNHCR, 2020). Those who experienced any form of GBV were asked whether they utilized post-GBV services, such as medical care support, legal aid, or social support services. FEWs were also asked to rate the quality of services they received.
Sociodemographic characteristics included study sites (Phnom Penh and other six provinces), place of birth, age, current marital status, number of children, and average monthly income in the past 3 months. We also collected information on their family's sociodemographic condition during childhood, education level, number of dependents, living arrangements, duration of work as an entertainment worker, and current entertainment venue. Additionally, we asked FEWs whether they had engaged in transactional sex work in the past 3 months.
Mental health was measured using the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977). The scale consists of 20 questions to capture six symptoms of depression, including depressed mood, guilt or worthlessness, helplessness or hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance experienced in the past 7 days. Each question has a 4-point Likert scale ranging from 0 (never) to 3 (almost all the time (5–7 days)—the total CES-D score ranges from 0 to 60. The codes of four items (I felt I was just as good as other people, I felt hopeful about the future, I was happy, and I enjoyed life) were reversed to calculate the total score. Participants with a total CES-D score of ≥16 were defined as having depressive symptoms. The scale's criterion validity has been well established in Western (Radloff, 1977) and Asian (Shima et al., 1985) populations. The Cronbach's alpha for the CES-D among this study's participants was 0.87.
Statistical Analyses
We used EpiData for double data entry to prevent data entry errors and STATA version 16 (StataCorp, LP, Texas, USA) for data analyses. We conducted descriptive analyses of the utilization and perceived service quality among FEWs who experienced GBV in the past 12 months. The Chi-square test (or Fisher's exact test when the sample sizes were smaller than five in one cell) for categorical variables and Student's t-test for continuous variables were conducted to explore the relationship between sociodemographic characteristics and depressive symptoms with post-GBV services utilization.
We performed a multiple logistic regression analysis to examine factors associated with post-GBV services utilization. In the model, we first added age, education, and all variables related to the utilization of the post-GBV services at a p-value <0.25 in bivariate analyses. Age and education were locked in the models regardless of their significance level as they are known potential confounders (Greenland et al., 2016). Then, we used a backward elimination method to eliminate variables with the highest p-value one by one from the multiple logistic regression models until all p-values of the remaining variables were <0.05. Overall, we ran 10 multiple logistic regression models. We obtained adjusted odds ratios (AOR) with 95% confidence intervals (CI) and presented them with p-values.
Ethical Considerations
The National Ethics Committee for Health Research of the Ministry of Health in Cambodia approved this study (N222NECHR). Before the interviews started, participants were informed about the study's objectives and the risks and benefits of their participation. Participation was voluntary, and the participants could refuse or discontinue the study anytime. We protected participants’ privacy and confidentiality by conducting the interviews privately and using personal identification numbers instead of personal identifiers. Trained GBV and counseling service providers were made available to FEWs when needed throughout the study period.
Results
Post-Gender-Based Violence Services
Among 299 FEWs who experienced any form of GBV in the past 12 months, 14.05% utilized GBV services, including medical care (50.00%), legal aid (52.38%), and social support (16.67%) services. Detailed information on post-GBV services utilization and perceived service quality among FEWs is presented in Table 1.
| Services utilization and perceived access of services | n (%) |
|---|---|
| FEWs who utilized any post-GBV services | 42 (14.05) |
| Sought for medical care supports | 21 (50.00) |
| Outpatient services/family planning | 12 (57.14) |
| STIs/HIV testing | 11 (52.38) |
| Perceived post-GBV medical care services quality as good | 20 (95.24) |
| Sought for legal aid | 22 (52.38) |
| Police services | 19 (86.36) |
| Legal aid from the government/NGOs | 5 (22.73) |
| Perceived post-GBV legal-aid services quality as good | 15 (68.18) |
| Sought for social support services | 7 (16.67) |
| Counseling | 4 (57.14) |
| Other services | 3 (42.86) |
| Perceived post-GBV social support services quality as good | 6 (75.00) |
Note. GBV = gender-based violence; HIV = human immunodeficiency virus; NGO = non-governmental organization; STIs = sexually transmitted infections.
Socio-Demographic Characteristics and Depressive Symptoms
As shown in Table 2, 57.86% of the participants were recruited from venues based in Phnom Penh. More than half of these FEWs (50.50%) had engaged in transactional sex work in the past 3 months. Only 22.07% were born in the provinces in which they were living. The mean age of participants was 26.79 (SD 5.74) years. Participants who had utilized post-GBV services were significantly older than those who had not (28.40 years vs. 26.53 years). Interestingly, the mean years of schooling were significantly higher among participants who had not utilized post-GBV services than those who had (6.03 years vs. 4.93 years). The proportion of participants who were married (38.10% vs. 19.84%), had two or more children (47.61% vs. 23.74%), lived with friends or family members (17.07% vs. 7.39%), worked at massage parlors (21.43% vs. 8.56%), and had depressive symptoms (92.86% vs. 76.65%) were significantly higher among those who had utilized post-GBV services than that among participants who had not.
| Characteristics | Total (N = 299) | Utilized post-GBV services | ||
|---|---|---|---|---|
| Yes (n = 42) | No (n = 257) | p | ||
| Study sites | 0.15 | |||
| Phnom Penh | 173 (57.86) | 20 (47.62) | 153 (59.53) | |
| Provincesa | 126 (42.14) | 22 (52.38) | 104 (40.47) | |
| Engaged in transactional sex work in the past 3 months | 151 (50.50) | 27 (64.29) | 124 (48.25) | 0.05 |
| Place of birth | 0.14 | |||
| In the study site | 66 (22.07) | 13 (30.95) | 53 (20.62) | |
| Not in the study site | 233 (77.93) | 29 (69.05) | 204 (79.38) | |
| Mean age in years (SD) | 26.79 (5.74) | 28.40 (5.50) | 26.53 (5.74) | 0.049 |
| 18–24 | 109 (36.45) | 12 (28.57) | 97 (37.74) | 0.23 |
| 25–29 | 108 (36.12) | 14 (33.33) | 94 (36.58) | |
| 30–48 | 82 (27.42) | 16 (38.10) | 66 (25.68) | |
| Current marital status | 0.004 | |||
| Single | 92 (30.77) | 5 (11.90) | 87 (33.85) | |
| Married | 67 (22.41) | 16 (38.10) | 51 (19.84) | |
| Widow/separate/divorce | 140 (46.82) | 21 (50.00) | 119 (46.30) | |
| Number of children | 0.004 | |||
| 0 | 139 (46.49) | 12 (28.57) | 127 (49.42) | |
| 1 | 79 (26.42) | 10 (23.81) | 69 (26.85) | |
| ≥2 | 81 (27.09) | 20 (47.61) | 61 (23.74) | |
| Mean monthly income in the last three months in USD (SD) | 283.86 (169.33) | 284.29 (219.19) | 283.79 (160.26) | 0.99 |
| ≤120 | 17 (5.69) | 5 (11.90) | 12 (4.67) | 0.10 |
| 121–250 | 152 (50.84) | 23 (54.76) | 129 (50.19) | |
| >250 | 130 (43.48) | 14 (33.33) | 116 (45.14) | |
| Socioeconomic condition during childhood | 0.16 | |||
| Poor | 187 (62.54) | 27 (64.29) | 160 (62.26) | |
| Average | 111 (37.12) | 14 (33.33) | 97 (37.74) | |
| Cannot recall | 1 (0.33) | 1 (2.38) | 0 (0.00) | |
| Mean years of education attained (SD) | 5.87 (3.32) | 4.93 (3.54) | 6.03 (3.27) | 0.05 |
| No schooling/Primary school (0–6) | 163 (54.52) | 28 (66.67) | 135 (52.53) | 0.26 |
| Secondary school (7–9) | 100 (33.44) | 11 (26.19) | 89 (34.63) | |
| High school or above (≥10) | 36 (12.04) | 3 (7.14) | 33 (12.84) | |
| Number of dependents | 0.09 | |||
| 0–1 | 58 (19.40) | 4 (9.52) | 54 (21.01) | |
| 2–3 | 131 (43.81) | 17 (40.48) | 114 (44.36) | |
| ≥4 | 110 (36.79) | 21 (50.00) | 89 (34.63) | |
| Single earner | 129 (46.07) | 16 (40.00) | 113 (47.08) | 0.41 |
| Currently living with: | 0.13 | |||
| Alone | 51 (17.06) | 6 (14.29) | 45 (17.51) | |
| Family/relative | 110 (36.79) | 10 (23.81) | 100 (38.91) | |
| Friends/colleague | 82 (27.42) | 14 (33.33) | 68 (26.46) | |
| Husband/sexual partner | 56 (18.73) | 12 (28.57) | 44 (17.12) | |
| Living conditionsb | 0.04 | |||
| In a rented room | 192 (64.43) | 20 (48.78) | 172 (66.93) | |
| Own house | 18 (6.04) | 5 (12.20) | 13 (5.06) | |
| With friends/family members | 26 (8.72) | 7 (17.07) | 19 (7.39) | |
| In workplace | 62 (20.81) | 9 (21.95) | 53 (20.62) | |
| Duration of work as entertainment workersb | 0.08 | |||
| Less than a year | 159 (53.36) | 21 (50.00) | 138 (53.91) | |
| 1–2 years | 82 (27.52) | 8 (19.05) | 74 (28.91) | |
| More than 2 years | 57 (19.13) | 13 (30.95) | 44 (17.19) | |
| Current venue of job in the entertainment | 0.014 | |||
| Restaurants/cafés | 53 (17.73) | 4 (9.52) | 49 (19.07) | |
| Massage parlors | 31 (10.37) | 9 (21.43) | 22 (8.56) | |
| Karaoke/dance club/beer garden | 210 (70.23) | 27 (64.29) | 183 (71.21) | |
| Street-based/freelance sex workers | 5 (1.65) | 2 (4.76) | 3 (1.17) | |
| Depressive symptoms | 236 (78.93) | 39 (92.86) | 197 (76.65) | 0.02 |
a
Provinces included Banteay Meanchey, Battambong, Kampong Cham, Pursat, Siem Reap, and Preah Sihanouk.
b
Missing one sample.
Factors Associated with Post-GBV Services Utilization
Table 3 shows factors associated with post-GBV services utilization after controlling for other covariates in multiple logistic regression models. The odds of post-GBV services utilization were significantly higher among participants who were married (AOR = 6.89, 95% CI = 1.94–24.39) and lived with friends or family members (AOR = 4.79, 95% CI = 1.57–14.64) than those among participants who were single and lived in a rented room, respectively. Regarding the entertainment venues, participants who worked at massage parlors were 4.37 (95% CI = 1.10–18.89) times more likely to utilize post-GBV services than participants who worked at restaurants/cafés. Likewise, participants who had depressive symptoms were 5.36 (95% CI = 1.18–24.28) times more likely to utilize post-GBV services than participants who did not have depressive symptoms.
| Variables in the final modela | Utilized post-GBV services | |
|---|---|---|
| AOR (95% CI) | p | |
| Age group (in years) | ||
| 18–24 | Reference | |
| 25–29 | 0.62 (0.24–1.64) | 0.34 |
| 30–48 | 0.89 (0.33–2.39) | 0.82 |
| Current marital status | ||
| Single | Reference | |
| Married | 6.89 (1.94–24.39) | 0.003 |
| Widowed/separated/divorced | 2.73 (0.84–8.83) | 0.09 |
| Education level (years) | ||
| High school or above (≥10) | Reference | |
| Secondary school (7–9) | 1.87 (0.35–10.13) | 0.47 |
| No schooling/Primary school (0–6) | 2.85 (0.55–14.73) | 0.21 |
| Living conditions | ||
| In a rented room | Reference | |
| Own house | 2.63 (0.66–10.42) | 0.17 |
| With friends/family members | 4.79 (1.57–14.64) | 0.006 |
| In workplace | 1.47 (0.54–3.99) | 0.45 |
| Current venue of job in the entertainment | ||
| Restaurants/cafés | Reference | |
| Massage parlors | 4.37 (1.10–18.89) | 0.048 |
| Karaoke bar/dance club/beer garden | 2.07 (0.62–6.86) | 0.24 |
| Street-based/freelance sex workers | 4.70 (0.42–52.17) | 0.21 |
| Depressive symptomsb | ||
| No | Reference | |
| Yes | 5.36 (1.18–24.28) | 0.03 |
Note. AOR = adjusted odds ratio; CI = confidence interval.
a
The remaining variables in the final multiple logistic regression.
b
Defined by a Center for Epidemiology Studies Depression Scale (CES-D) score of ≥16.
Discussion
We conducted this study among FEWs who experienced GBV to examine factors associated with post-GBV services utilization. We found that only 14.05% of FEWs sought services following the violence. A study among FSWs, men who have sex with men (MSM), and transgender women in four countries in America and the Caribbean found that most participants said that GBV services did not meet their needs, or the service providers further abused them (Evens et al., 2019). Many of them did not seek post-GBV assistance because they did not think they would get the help they needed or did not think the services were available (Evens et al., 2019). Such low post-GBV services utilization among FEWs suggests a need to explore other modified factors related to increasing services utilization following the violence.
We found the odds of post-GBV services utilization were significantly higher among those who were married and those who lived with friends/family members compared to those who were single and lived in a rented room. A plausible explanation for this finding might be that intimate partners, friends, and family members were FEWs’ social supporters. FEWs might be more likely to seek emotional support within their accessible support systems, such as friends, colleagues, or family members. This finding is consistent with a qualitative study in the United States that examined the experiences of FSWs who survived sexual assault (Shepp et al., 2020). The result revealed that some informal supporters, including family, friends, and intimate partners, expressed their empathy and understanding of the survivors (Shepp et al., 2020). Informal supporters could encourage women to seek services following the experience of violence.
FEWs who had depressive symptoms were associated with seeking post-GBV services. Other studies among FSWs (Varga & Surratt, 2014) and MSM (Ulanja et al., 2019) reported similar findings. The odds of healthcare utilization for MSM significantly increased among those who screened positive for depression, as measured by the Patient Health Questionnaire (Ulanja et al., 2019). Likewise, a study among Black female street-based sex workers found that depressive symptoms, evaluated by the General Mental Distress Scale based on DSM-IV symptom criteria, were one of the vulnerable statuses contributing to the likelihood of visiting a health care professional (Varga & Surratt, 2014). Being FEWs, particularly those engaged in sex work, face a greater risk for health problems than general women due to the work conditions and environment (Deering et al., 2014; Patel et al., 2015; Wong et al., 2012). It is crucial to have linkages and resources for FEWs to utilize services when needed.
We also found that the odds of seeking post-GBV services were significantly higher among FEWs working at massage parlors than those working at restaurants/cafés. FEWs working at massage parlors received more support from civil society organizations regarding access to services and referrals when experiencing violence than those who worked at restaurants/cafés. Different workplaces provide different motivations for FEWs to seek assistance. For example, a study among FSWs in the Mekong Delta Region of Vietnam found that street-based sex workers received more support from peer educators and civil society organization officers than establishment-based sex workers (Tran et al., 2014). Future interventions to improve access to services among FEWs might be implemented regardless of the type of entertainment venues.
Policy Implications
Results from this study provide crucial information for program implementation and policy to improve the uptake of post-GBV services utilization among FEWs in Cambodia. Since the post-GBV services can often be context-specific due to the country's quality and availability of the existing prevention and services, context-specific interventions are required to improve post-GBV services utilization. For instance, the Mobile Link intervention, an operational mHealth implementation research program linking FEWs in Cambodia to the existing prevention, care, and treatment services, was found to reduce the rate of forced drinking at work, effectively connect FEWs with outreach workers and escort referrals compared to the control group (Brody et al., 2022). Another important implication of this study is mental health support for FEWs, especially those who experienced GBV. Mental health issues are even more critical to tackle among FEWs during the COVID-19 pandemic (Shareck et al., 2021).
Lastly, findings from this study imply that, while addressing individual-level factors is necessary to increase service uptake among FEWs who experienced GBV, it might not be sufficient. To meaningfully connect FEWs with services following the violence, a community-based intervention might be required. For example, a review of the evidence-based strategies for engaging sex workers with HIV prevention and care programs found that the quality, comprehensive, community-driven evidence-based programs can improve the uptake of and engagement of sex workers in the HIV prevention and care (Cowan et al., 2019). Similarly, the Key Population-led Health Services (KPLHS) model, established in Thailand in 2015, efficiently prevented HIV infections, loss to follow-up, and earlier treatment initiation (Vannakit et al., 2020). In the KPLHS model, the community identified the services; therefore, it is a needs-based, demand-driven, and client-centered model. The services are then delivered by trained and qualified lay providers who usually are members of the key populations. The KPLHS model can potentially be adapted to other key populations such as FEWs, focusing on improving service utilization among women who experience GBV.
Limitations of the Study
Few limitations were inherent in this study. First and foremost, we could not draw a causal inference between the factors associated with post-GBV services utilization among FEWs in Cambodia embedded in the cross-sectional study design. Both exposure and outcome of interest were ascertained simultaneously; therefore, a temporal link could not be established (Rothman et al., 2008). Second, since women were asked about sensitive issues, such as GBV and mental health, FEWs might be less likely to report such information, resulting in underestimating the proportion of these variables. Accordingly, social desirability bias might be present in this study (Guest et al., 2005). However, we minimized this bias by adapting a validated and structured questionnaire and training female interviewers to deal with sensitive personal information. The final study's limitation concerns the findings’ generalizability. Since FEWs were recruited under KHANA's coverage areas, this study's results might not be generalizable to other FEWs not receiving services from the organization.
Conclusion
Our study found a relatively low proportion of Cambodian FEWs seeking post-GBV services utilization. Factors associated with seeking post-GBV services following the violence were marital status, living conditions, mental health, and types of entertainment venues. These findings indicate that intervention programs to improve support from accessible systems, such as friends, colleagues, or family members, may increase the proportion of FEWs seeking post-GBV services. Individual-based behavioral change interventions would not be sufficient to improve the likelihood of FEWs seeking post-GBV services in Cambodia. More structural health and social interventions are required to ensure the quality and availability of medical care support, legal aid, and social services.
Acknowledgments
The authors thank stakeholder representatives, data collectors, and study participants who contributed considerably to this study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The United States Agency for International Development funded this study through the “HIV/AIDS Flagship Project.” SO, CS, and SYi were partially supported by Saw Swee Hock School of Public Health, National University of Singapore through the UHS-SSHSPH Integrated Research Program (USIRP).
ORCID iDs
Sreymom Oy https://orcid.org/0000-0001-9796-0080
Sovannary Tuot https://orcid.org/0000-0001-8617-4578
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Biographies
Sreymom Oy, MS, is a Research Associate at UHS-SSHSPH Integrated Research Programme, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System. Her research focuses on maternal and child health and nutrition, infectious disease prevention and control, and sexual and reproductive health among marginalized and key populations.
Chan Hang Saing, PhD, is currently a Research Fellow at Saw Swee Hock School of Public Health, National University of Singapore and National University Health System. His primary areas of interest include development economics, applied microeconomics, poverty, inequality, trade, investment and growth, infectious diseases, and non-communicable diseases.
Sokunthea Yem, MHEP, is currently a Health Economist at the National Institute of Public Health in Cambodia. She is currently working on scaling up care for diabetes and hypertension in Cambodia. Her research of interest includes health financing, costing, economic evaluation, and tracking the progress of universal health coverage.
Pheak Chhoun, MPH, is currently a Research Fellow at KHANA Center for Population Health Research in Cambodia. He has extensive experience working with community-based organizations to improve the health and quality of life of key and marginalized populations in Cambodia.
Sovannary Tuot, MA, is a manager at KHANA Center for Population Health Research in Cambodia. He has more than 10 years of programs and research experience in community-based interventions for improving HIV and other health outcomes of populations infected and affected by HIV in Cambodia.
Siyan Yi, PhD, is an Assistant Professor at Saw Swee Hock School of Public Health, National University of Singapore and National University Health System. He also serves as director of KHANA Center for Population Health Research, Cambodia. His research focuses on community-based interventions for improving HIV and sexual and reproductive health outcomes of vulnerable and marginalized populations in Cambodia.
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Article first published online: January 8, 2023
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PubMed: 36617944
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Authors’ Contributions
SYi, ST, and SYe designed the study and developed the research protocol. SYe, ST, and PC planned, coordinated, and supervised data collection. SO and CS analyzed the data, interpreted the findings, and wrote the manuscript. All authors reviewed the study's findings and edited the manuscript. All authors read and approved the final manuscript.
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