Promoting psychosocial health and empowerment among female sex workers in Nepal: a pilot peer education intervention

2016 Summer.Includes bibliographical references.Across contexts, female sex workers (FSWs) may be exposed to varying degrees and combinations of risks in their work, including but not limited to long hours, poor working conditions, disease transmission, unplanned pregnancy, violence, drug and alcohol use and abuse, debt, and various forms of harassment, discrimination, and exploitation. It is likely that the risks associated with sex work are greater in developing countries where sex workers have a low and stigmatized status, minimal capacity to earn an adequate income, limited level of control regarding clients accepted and services rendered, and restricted access to sufficiently resourced health and other services and support structures. The sex industry in Nepal is synonymously referred to as the entertainment sector. Women in the entertainment sector (WES) in Nepal are vulnerable to an array of occupational risks, which compromise their psychosocial health and empowerment, in turn limiting their ability to thrive and engage in protective behaviors. The present study involved the pilot test of a peer education intervention in collaboration with a non-governmental organization (NGO) to empower and promote the psychosocial and occupational health of WES in Kathmandu, Nepal. Ten WES were trained as peer educators (PEs) and, through formal and informal teaching opportunities, reached over 140 FSWs with psychosocial health promotion messages. In addition to a detailed literature review, method, and discussion, this dissertation comprises three manuscripts. The first manuscript presents results from a quasi-experimental pre/post evaluation with 160 WES, including those who were (n = 96) and were not (n = 64) exposed to the PEs, to assess the impact of the program on psychosocial and occupational health and empowerment outcomes. Results indicate that WES who were exposed to the psychosocial health promotion messages of the PEs reported significantly improved psychosocial health knowledge and perceived self-efficacy, ability to access resources, happiness, and job control compared to WES who were not exposed to the PEs. The second manuscript presents results from a mixed-methods evaluation to assess the feasibility of the program and its impact on the psychosocial and occupational health and empowerment of the 10 WES trained as PEs. PEs were surveyed at baseline, immediately post intervention, after 2-months, and after 10-months to evaluate psychosocial and occupational health, empowerment, and peer education efficacy. Upon completion of the program, one-on-one exit interviews were conducted with nine of the PEs and two field staff from the partner NGO to solicit more in-depth feedback about the program. PE survey results indicate the program had a significant impact on some aspects of psychosocial health and empowerment, with positive trends on many other variables. Exit interviews revealed additional positive impacts of the program, including enhanced confidence and communication skills and increased self-awareness and self-care behaviors. Overall, the findings presented in these two manuscripts suggest peer education is both a feasible and promising means to enhance the psychosocial and occupational health and empowerment of WES in Nepal. The third manuscript details the processes implemented in this pilot study. Peer education methods have been established as a promising way to reach FSWs and other vulnerable and hard-to-reach populations with health promotion programming; however, there is scant published information about how such programs are designed and implemented. This lack of process information contributes to poor clarity regarding how to effectively develop and execute peer education programs and increases the propensity for repetition among failed strategies. Using this pilot program as an example, this manuscript offers an in-depth vantage point into the black box of peer education by outlining the specific steps taken while designing, implementing, and evaluating the program. While considering each phase of the project, the challenges encountered along the way as well as the effective strategies implemented to overcome them are reviewed, with a focus on offering practical tips and strategies. Conclusions and a summary of recommendations for those interested in implementing similar programs are discussed. These three manuscripts as a whole can be used to inform future interventions aiming to enhance the psychosocial and occupational well-being and empowerment of sex workers and other vulnerable and hard-to-reach working populations through peer education methods