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Environmental Support and HIV Prevention Behaviors Among Female Sex Workers in China


Sexually Transmitted Diseases: July 2008 - Volume 35 - Issue 7 - p 662-667
doi: 10.1097/OLQ.0b013e31816b322c

Objective: To examine the influence of environmental support on HIV prevention behaviors (i.e., condom use behaviors, communication and intention, and HIV/STD testing) among female sex workers (FSWs) in China.

Methods: A cross-sectional survey was administered among 310 FSWs recruited from entertainment establishments in Liuzhou City in Southwest China in 2006. Sex workers were asked about their demographic and working characteristics and their HIV prevention behaviors. Environmental support was measured by a scale consisting of 8 items regarding condom availability, managerial, and social support of HIV prevention (Cronbach α = 0.73).

Results: After adjusting for demographic and working characteristics, condom use self-efficacy and knowledge, environmental support was strongly associated with following HIV prevention behaviors: overall consistent condom use (aOR = 1.7, 95% CI = 1.3, 2.3), consistent condom use in the last 3 sexual acts (aOR = 1.5, 95% CI = 1.1, 2.0), intention to use condoms consistently (aOR = 1.6, 95% CI = 1.1, 2.2), and HIV testing (aOR = 1.6, 95% CI = 1.1, 2.2).

Conclusion: Environmental support is a significant predictor of HIV prevention behaviors among establishment-based FSWs in China. The data underscore the importance of developing environmental/structural HIV/STD interventions for FSWs. Condoms need to be easily accessible in the establishments. Gatekeepers need to be educated to create a supportive environment for condom use and HIV prevention.

Data from 310 establishment-based female sex workers in China revealed that their perceived environmental support for HIV prevention was strongly associated with their condom use behaviors and HIV testing.

From the *Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas; †Institute of Developmental Psychology, Beijing Normal University, Beijing, China; ‡Prevention Research Center, Wayne State University School of Medicine, Detroit, Michigan; and §City Center for Disease Control and Prevention, Liuzhou, China

The authors thank all our participants and the strong support from Liuzhou Center of Disease Control in Guangxi. They also thank Dr. Dudley Poston for his input in the manuscript revision.

Supported by a grant from Global Fund to Fight AIDS Tuberculosis and Malaria, China Program (2006-015).

Correspondence: Yan Hong, PhD, Assistant Professor, Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M Health Science Center, 1266 TAMU, College Station, TX 77843-1266. E-mail:

Received for publication October 17, 2007, and accepted January 24, 2008.

IN THE PAST DECADE, THERE is an increasing attention on the role of environmental or structural factors in HIV prevention. Literature suggests that factors outside the control of cognition of individuals such as social norms, materials and human resources, policies and legislation that facilitate or constrain individual behaviors.1 Much of the HIV-related intervention research available to date concerning environmental factors has been conducted within the context of commercial sex.2 In many countries where commercial sex is illegal, the majority of female sex workers (FSWs) work in entertainment establishments such as bars, night clubs, disco houses, karaoke centers, and massage parlors. Entertainment establishments serve as the situational context for condom use practices for the FSWs. Previous studies in developing countries such as Philippines, Republic of Dominic, and Thailand suggested that environmental factors were strong predictors of condom use behaviors among FSWs.3–5 These studies have been successfully translated into effective environmental/structural interventions that promote condom use among FSWs in different countries.5–10

Although commercial sex is illegal in China, it has developed into a widespread and thriving industry since early 1980s.11,12 There are an estimated 4 million to 10 million women engaging in commercial sex.11 Like in many other countries, most of the FSWs work in entertainment establishments.13 The FSWs and their clients play a critical role in the growing HIV epidemic in China, as recent data revealed that a majority of heterosexual transmission of HIV was through commercial sex.14 Sexual transmission of HIV in China has been increasing rapidly fast in the past years and accounted for nearly 50% of new infection cases in 2005.14 Previous studies suggested that FSWs in China had high rates of risky sexual behaviors including low rates of condom use and high rates of STDs. According to a recent review, STD infection rates among FSWs ranged from 40% to 85%.12 Prevalence of HIV among surveillance sites of FSWs was approximately 1%, and it was as high as 10% in some sites.15 As some experts note that FSWs and their clients may serve as the “bridge population” linking high-risk groups (such as drug users and STDs) to the general population.11,16

A limited number of studies have documented the importance of environmental factors in FSWs' HIV risks. For example, FSWs' condom use behaviors were associated with the characteristics of their workplaces or their working conditions.16–18 A previous study also found a strong linkage between the gatekeepers' (managers or owners of the establishments) attitude and FSWs' condom use.19 However, there remains a lack of studies on environmental support on FSWs' HIV protection behaviors. Particularly, there is a lack of data on measuring environmental support that includes condom access, managerial, and social support. In addition, previous studies have primarily focused on consistent condom use, with insufficient data on other HIV prevention behaviors such as STD/HIV testing, proper use of condoms, and condom use communication. Given the escalating scale of HIV epidemic in China and the critical role of commercial sex in the epidemic, the current study will provide data to inform future effective environmental–structural interventions to reduce HIV risks among the vulnerable population of FSWs in China.

In this study, we conducted a baseline survey among 310 FSWs working in entertainment establishments in Guangxi, China. A scale was developed to measure the level of environmental support for condom use and HIV prevention. We examined the association of environmental support and HIV prevention behaviors, including condom use frequency, condom use communication, correct use of condom, HIV and STD testing, and condom use intention. We hypothesized that environmental support is positively associated with HIV protection behaviors after controlling for potential confounders, including demographic and working characteristics as well as condom use self-efficacy and condom use knowledge, as self-efficacy and knowledge of condom use were identified to be strong predictors of condom use.20

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Study Site

The data in the current study were drawn from the baseline assessment of a pilot HIV/STD prevention project, which was conducted in 2006 in Liuzhou City of Guangxi Zhuang Autonomous Region (“Guangxi”). Guangxi, 1 of China's 5 autonomous and multiethnic regions, is located in the southwest China, bordering Viet Nam. The prosperous economy and increased tourism in Guangxi have created a demand and market for commercial sex. With a population of 1.3 million, Liuzhou is the second largest city and the largest industrial center in Guangxi. The majority (60%) of the population in Liuzhou are Han Chinese, and the rest are minorities, with Zhuang minority being the largest group.21 Like other areas of Guangxi, there are many entertainment establishments in Liuzhou, providing commercial sex services.

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Participants and Survey Procedure

We used the data collection methods that were used in our previous study among FSWs in Guangxi.22 Participants in this study were recruited from entertainment establishments such as karaoke bars, massage parlors, restaurants, barbershops, and hair-washing rooms in Liuzhou City. The research team and local health workers identified entertainment establishments in Liuzhou through ethnographic mapping. The owners or managers of these establishments were contacted for their permission to conduct research in their premises. Once we obtained permission from the establishment owners or mangers, trained outreach health workers from the City Center for Disease Control and local hospitals approached women in the establishments to ask for their participation. A total of 310 women agreed to participate, provided written informed consent, and completed a self-administered questionnaire. Each participant received a financial incentive equivalent in value of US$2.50.

The survey was conducted in separate rooms or private spaces in the establishments where participants were recruited. No one was allowed to stay with the participant during the survey except the interviewer who provided the participant with necessary assistance. The questionnaire took about 45 minutes to complete. The study protocol was approved by the Institutional Review Board at Beijing Normal University in China. Permissions were also obtained from Liuzhou City Center for Disease Control to conduct the study.

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Environmental Support of Condom Use.

This scale was developed from existing literature on environmental support of condom use among FSWs and our qualitative interviews with participants in the formative phase of the study. The scale includes 8 items measuring condom availability, managerial and social support of condom use, and HIV prevention. The example items include“Condoms can be purchased in my workplace.” “My boss often discusses condom use with me”, and“If I refuse to serve a customer who doesn't want to use a condom, my boss will support me” (see Table 1 for a complete list of the items). The response options are dichotomized, with 1 = yes and 0 = no. The responses to 8 items were summed up and formed a continuous variable ranging from 0 to 8 with higher value indicating a higher level of environmental support. For the purpose of data analysis in this study, we categorize environmental support into 3 levels: low (scale score = 0–2), medium (scale score = 3–5), and high (scale score = 6–8).



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Demographic and Working Characteristics.

Women's demographic information collected in this study included their age, ethnicity (Han, Zhuang, and other minorities), years of formal schooling, hometown type (rural vs. urban), living arrangements (alone, with family, or with other FSWs), and current monthly income. Women's working characteristics included how long they have been working in commercial sex, number of FSWs in the workplace, and average clients they had per week.

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Condom Use Self-Efficacy.

This was a scale we used in previous studies on FSWs in China.19,23 It includes 5 items: “I know where to get condoms,” “if my partner is not willing to use condoms, I can persuade him,” “if my client is not willing to use condoms, I can persuade him,” “if my client refuses to use condoms, I will refuse to have sex with him,” and “I know how to use condoms properly.” The Cronbach α of this scale is 0.56. A composite score was created by summing positive responses of the 5 items.

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Knowledge of Correct Condom Use.

It was measured by asking participants to sort 6 preprinted pictorial cards describing major steps of condom use. Only those who arranged all the 6 cards in the correct order were considered to have the knowledge of correct condom use.

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Consistent Condom Use With Clients.

This was measured by 2 variables: overall frequency of condom use (never, occasional, sometimes, often, and always) and number of times used a condom during the 3 most recent sexual intercourses (none, once, twice, and 3 times). Participants who answered“always” to the first measure were categorized as consistent condom use with clients (overall frequencies). Participants who answered “three times” to the second measure were categorized as consistent condom use in the last 3 sexual acts.

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Condom Use Communication.

It was measured by 1 item (“if you ever discussed condom use with your clients”) with a dichotomous response (yes/no).

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Proper Use of Condom.

It was measured by 1 variable of “how often you/your client put on a condom before insertion (never, occasionally, sometimes, often, and always).” Those who answer “always” to this question were considered to use condoms properly.

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HIV/STD Testing.

This was measured by 1 item asking if they had ever tested for HIV or STD. Two separate indicators were created based on their responses to the item: those who had tested HIV were considered to have had HIV testing; those who had tested STD were considered to have had STD testing.

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Intention to Use Condoms Consistently in the Next 6 Months.

This was measured by one variable of how often they plan to use a condom in the next 6 months (never, occasionally, sometimes, often, and always). Those who answer “always” were considered to have the intention to use condoms consistently in the next 6 months.

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Data Analysis

First, responses to individual items of the environmental support scale were presented in a contingency frequency table. The scale's internal consistency (measured by Cronbach α) and item-total correlation were also calculated. Second, the relationship between level of environmental support and FSWs' demographic and working characteristics were tested using χ2 (for categorical variable) or analysis of variance (for continuous variables). Then, the association between environmental support and FSWs' HIV protection behaviors were examined in 2 steps of analysis. First step is bivariate analysis in which percentages of each dependent variables (7 HIV prevention behaviors) were tabulated by level of environmental support using χ2 test. Second step is multivariate logistic regressions in which the association between environmental support and each of the 7 HIV prevention behaviors was examined. In each of the multivariate analyses, we adjusted for potential confounders including FSWs' demographic characteristics (i.e., age, ethnicity, education, hometown type, marital status, income), working characteristics (i.e., length of working as an FSW, number of FSWs in the workplace), and condom use self-efficacy and knowledge of correct use of condom. Adjusted odds ratios (aOR) and its 95% confidence intervals (95% CI) were calculated for the multivariate models. All statistical analyses were performed using the Stata 8.0 statistical software package.

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Environmental Support

As shown in Table 1, for 8 items measuring different environmental support of condom use and HIV prevention for FSWs, the participants' positive responses ranged from 20% to 87%, with a mean score of 4.4 (SD = 2.1). The item-total correlation ranged from 0.4 to 0.7. The Cronbach α of the scale is 0.73.

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Demographic and Working Characteristics and Their Association With Environmental Support

The participants had a mean age of 22.5 (SD = 3.9) years. Nearly a half of the participants were of Han ethnicity (the ethnic majority in China, accounting for 92% of the total Chinese population). Zhuang ethnicity constituted about 41% of the sample, and the remaining 9.7% were of other ethnic minorities. More than half of the women (56.8%) were from rural areas and the rest came from urban areas (including county seats, small cities, and big cities). The average years of schooling were 8.5 (SD = 2.7), with 23% having elementary school education or less, 48% completing middle school education, and 30% completing high school education. The majority (85%) of the women was single and more than one-half (51%) of them lived with boyfriends or other family members. Participants' monthly income ranged from 300 to 20,000 Yuan (8 Yuan ≈ 1 US$ at the time of study), with a mean of 1783.2 Yuan. Their time of working as an FSW ranged from 0.5 to 96 months, with a mean of 12 (SD = 12) months. More than half of the FSWs worked in establishments with 9 or fewer FSWs, approximately 20% worked in establishments with 10 to 20 FSWs, and the remaining (25%) worked in places with more than 20 FSWs. Their average numbers of clients per week ranged from 1 to 35, with a mean of 7.5. A majority (81%) of women had knowledge of correct use of condom, and the mean score of condom use self-efficacy was 3.9 (SD = 1.2).

As shown in Table 2, FSWs' perceived level of environmental support was associated with their marital status and education level. In addition, women working in larger entertainment establishments reported less environmental support compared with women working in smaller establishments. Self-efficacy of condom use was also strongly positively associated with level of environmental support.



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Relationship of Environmental Support and HIV Prevention Behaviors

Table 3 presents rates of FSWs' HIV prevention behaviors and their association with environmental support. Overall, about 55% of the FSWs always used condoms with their clients, and two-thirds of FSWs used condoms every time in the past 3 sex acts with clients. Nearly 80% of the women had condom use communication with clients, and 72% had used condoms correctly with clients. Only 31% of women were ever tested for STD and 24% were ever tested for HIV. About 72% of women had the intention to use condoms consistently in the next 6 months.



The bivariate analyses indicate that environmental support was significantly associated with all 7 HIV prevention behaviors. FSWs who perceived higher level of environmental support reported higher rates of consistent condom use (overall frequency and last 3 sexual acts), condom use communication, correct condom use, HIV/STD testing, and intention of consistent condom use. To further examine the effect of environmental support on FSWs' HIV prevention behaviors, multivariate analyses were performed for each of the 7 HIV prevention behaviors while adjusting for FSWs' demographic and working characteristics as well as their self-efficacy of condom use and knowledge of correct condom use. Environmental support was still a significant correlate for 4 of the 7 HIV prevention behaviors: overall consistent condom use (aOR = 1.7; 95% CI = 1.3, 2.3), consistent condom use in the last 3 sexual acts (aOR = 1.5; 95% CI = 1.1, 2.0), HIV testing (aOR = 1.6; 95% CI = 1.1, 2.2), and intention to use condoms consistently (aOR = 1.6; 95% CI = 1.1, 2.2).

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The current study represents one of the first empirical studies to examine the relationship between HIV prevention behaviors and environmental factors among FSWs in China. It also reports a reliable scale of environmental support that includes elements of condom use availability, gatekeeper support, and communication regarding condom use and HIV prevention. The findings confirm the importance of environmental support in FSWs' HIV prevention behaviors. Our data demonstrate that environmental support was associated with not only the FSWs' consistent condom use, but also their intention to use condoms and HIV testing. A recent review on existing studies of FSWs in China indicates a lack of environmental–structural interventions to reduce HIV risks among this high-risk population.12 The current study underscores the importance of interventions that go beyond individual knowledge, attitudes, and skills and incorporate environmental factors to reduce HIV risks among FSWs and their partners.

Our data evidenced the multiple factors of environmental support, such as availability of condoms, gatekeepers' support, communication between gatekeeper, and FSWs as well as among peer FSWs regarding condom use and HIV prevention. Such findings suggest that development of effective environmental–structural interventions should incorporate elements of physical, social, and policy environment of commercial sex that are critical in promoting condom use and other HIV preventive measures. Increasing condom use among FSWs and their partners requires much more than merely provision of condoms in the establishments. Interventions should not only seek to increase access to condoms in sex establishments, but also promote institutional and community-based solidarity among sex workers and gatekeepers to increase condom use and prevent HIV/STD. In addition, condom use policies need to be clearly articulated by gatekeepers, who need to communicate frequently with FSWs and other establishment employees to promote positive social norms on condom use and HIV prevention. Our data also indicated that level of perceived environmental support was associated with FSWs' demographic and working characteristics (e.g., married FSWs and those working in large establishments perceived a low level of support). Culturally appropriate intervention programs are needed to target different subgroups of FSWs.

Unlike other countries such as Thailand, Philippines, and Dominica where sex workers are required to register at the local health clinics for regular checkups,3–5 in China, unlawful commercial sex is considered one of the “social evils” by the government and face periodic crackdown from law enforcement agencies.12 Therefore, FSWs in China are less likely to have HIV/STD testing and mandatory requirement of condom use policy by the government is difficult; HIV/STD prevention intervention among this population is even more challenging.12 Although it is unrealistic to expect a rapid change in governmental policy or legislature at the national level toward commercial sex, we call for more practical approaches to promote condom use and HIV prevention among FSWs. The current study suggests that under the current social and political circumstances in China, feasible and effective interventions to reduce HIV risks among FSWs may include the following components: insuring the establishments provide condoms to their FSWs, training gatekeepers to establish condom use policy, and create a positive norm on condom use behaviors and communication. Targeted trainings are also needed to increase gatekeepers' and FSWs' HIV knowledge communication skills, and condom use skills. Meanwhile, public health professionals need to work with other societal sectors and stakeholders to advocate for legislative reform to protect sex workers' health and human rights. Such approach is fundamental “environmental support” for FSWs.

The current study has several limitations. First, the study uses a cross-sectional design that limits our ability to establish causal association. Second, the convenient nature of our sample limits the generalization of the findings. However, the demographic and working characteristics of our sample and their HIV prevention behaviors were similar to those reported in previous studies of FSWs in China.16,17,19,22 Third, there are potential volunteer bias and self-report bias, given it was a community-based study and participants were recruited through community outreach. Finally, the scale of environmental support measures FSWs' perceived environmental support, gatekeepers' perception of environmental support was not available. In addition, there is no observed, establishment-level data, for example, the actual supply of condom use.

In summary, environmental factors are significant predictors of HIV prevention behaviors among FSWs in China. The data underscore the importance to develop environmental–structural HIV/STD interventions. In addition to improving FSWs' knowledge, efficacy, and skills of condom use, health workers should work with gatekeepers to create a supportive environment for HIV prevention in establishments, and condoms need to be easily accessible in the establishments. Gatekeepers should also be educated regarding the importance of condom use communication, HIV/STD testing, and their clear support for FSWs who insist on condom use with clients.

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