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      Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review

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          Abstract

          Background

          Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.

          Methods

          In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.

          Results

          Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.

          Conclusions

          Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.

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          Most cited references 132

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          Sexual behaviour in context: a global perspective.

          Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.
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            Structural interventions: concepts, challenges and opportunities for research.

            Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced. They draw on concepts from multiple disciplines, including public health, psychiatry, and psychology, in which attention to interventions is common, and sociology and political economy, where structure is a familiar, if contested, concept. This has meant that even as discussions of structural interventions bring together researchers from various fields, they can get stalled in debates over definitions. In this paper, we seek to move these discussions forward by highlighting a number of critical issues raised by structural interventions, and the subsequent implications of these for research.
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              The Sonagachi Project: a sustainable community intervention program.

              High rates of HIV infection among sex workers in India indicate the importance of understanding the process of establishing a sustainable community intervention program. The Sonagachi Project, based in Calcutta, India, has been associated with lower HIV rates among sex workers as compared to other urban centers in India. The program defined HIV as an occupational health problem and included multifaceted, multilevel interventions addressing community (having a high-status advocate; addressing environmental barriers and resources), group (changing social relationships), and individual factors (improving skills and competencies related to HIV prevention and treatment). The Sonagachi Project's core concepts and strategies evolved as community needs were expressed and defined. In particular, the program was not initially conceptualized as a community empowerment project but emerged over time, allowing for project sustainability. Project components appear to be replicable across settings within India and worldwide.
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                Author and article information

                Contributors
                Journal
                Global Health
                Global Health
                Globalization and Health
                BioMed Central
                1744-8603
                2014
                10 June 2014
                : 10
                : 47
                Affiliations
                [1 ]MatCH (Maternal, Adolescent and Child Health), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
                [2 ]Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
                [3 ]International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
                [4 ]Wits Reproductive Health and HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
                [5 ]Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
                [6 ]Community Health Sciences, University of Manitoba, Manitoba, Canada
                [7 ]Institute of Tropical Medicine, Antwerp, Belgium
                Article
                1744-8603-10-47
                10.1186/1744-8603-10-47
                4074148
                24916108
                Copyright © 2014 Moore et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research

                Health & Social care

                community mobilisation, female sex workers, structural interventions, africa

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