Article thumbnail

A Multilevel Analysis of the Impact of Socio-Structural and Environmental Influences on Condom Use Among Female Sex Workers

By Alfonso Ang and Donald E. Morisky


This study uses multilevel analysis to examine individual, organizational and community levels of influence on condom use among female commercial sex workers (FSW) in the Philippines. A randomized controlled study involving 1,382 female commercial sex workers assigned to three intervention groups consisting of peer education, managerial training, combined peer and managerial intervention and a usual care control group was conducted. The results of the multilevel analysis show that FSWs who work in establishments with condom use rules tend to have a higher level of condom use (β = .70, P < 0.01). Among the different intervention groups, the combined peer and managerial intervention had the largest effect on condom use (β = 1.30, P < 0.01) compared with the usual care group. Using a three-level hierarchical model, we found that 62% of the variation lies within individuals, whereas 24% and 14% of the variation lies between establishments, and communities, respectively. Standard errors were underestimated when clustering of the FSWs in the different establishments and communities were not taken into consideration. The results demonstrate the importance of using multilevel analysis for community-based HIV/AIDS intervention programs to examine individual, establishment and community effects

Topics: Original Paper
Publisher: Springer US
OAI identifier:
Provided by: PubMed Central

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.

Suggested articles


  1. A community participatory action research approach (P.A.R.) to HIV/ AIDSpreventionamongsexworkers.PromotEduc.1996;3(4):25–8.
  2. (1999). A pragmatic intervention to promote condom use by female sex workers in Thailand. Bull World Health Organ.
  3. (2008). A snapshot of community-based research in Canada: Who? What? Why? How? Health Educ Res.
  4. (2004). Applications of hierarchical linear models for evaluations of health interventions: demystifying the methods and interpretations of multilevel models. Eval Health Prof.
  5. Changing behaviors and patterns among Cambodian sex workers: 1997–2003.
  6. (2008). Community action for preventing HIV in Cambodia: evaluation of a 3-year project. Health Policy Plan.
  7. Community-based research partnerships: challenges and opportunities.
  8. (2005). Communitybased participatory research (CBPR) in South Africa: engaging multiple constituents to shape the research question. Soc Sci Med.
  9. Condom use and other HIV risk issues among Nigerian soldiers: challenges for identifying peer educators.
  10. (2012). Early detection: the next steps.
  11. (2000). Evaluating AIDS prevention interventions using behavioral and biological outcome measures. Sex Transm Dis.
  12. Factors affecting client response to HIV outreach efforts.
  13. (1988). Fisher scoring algorithm for variance component analysis of data with multilevel structure.
  14. (1992). hedonistic expectancies, and condom-use intentions among inner-city Black adolescent women: a social cognitive approach to AIDS risk behavior. J Adolesc Health.
  15. (2002). Hierarchical linear models: applications and data analysis methods. 2nd ed.
  16. (2002). HIV infection in young men in northern Thailand, 1991–1998: increasing role of injection drug use. J Acquir Immune Defic Syndr.
  17. (2007). HIV prevention in sub-Saharan Africa: a multilevel analysis of message frames and their social determinants. Health Promot Int.
  18. (2004). HLM 6: hierarchical linear and nonlinear modeling. Scientific Software International,
  19. (2006). Impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines: a multilevel analysis. Health Psycho.
  20. (2001). Implementing community-based participatory research centers in diverse urban settings. J Urban Health.
  21. (2002). Knowledge and perception of risk for HIV and condom use among male injecting drug users in Cebu City, Philippines. Drug Alcohol Rev.
  22. (2000). Male-condom and femalecondom use among women after counseling in a risk-reduction hierarchy for STD prevention. Sex Transm Dis.
  23. (1999). Multilevel analysis: An introduction to basic and advanced multilevel modeling.
  24. (2003). Multilevel statistical models. 3rd ed.
  25. (2004). Multiple imputation of missing values.
  26. (2000). Multiple levels of analysis and intervention in HIV prevention science: exemplars and directions for new research.
  27. Place matters: multilevel investigation of HIV distribution in Tanzania.
  28. Sexual partners and condom use of migrant workers in Thailand.
  29. Sexually transmitted diseases: magnitude, determinants and consequences.
  30. Study Group on Heterogeneity of HIV Epidemics in African Cities. The role of context neighbourhood characteristics strongly influence HIV risk in young womeninNdola,Zambia.TropMedIntHealth2008;13(2):162–70.
  31. (1995). Superstar’’ and ‘‘Model Brothel’’: developing and evaluating a condom promotion program for sex establishments in Chiang Mai,
  32. The catch 22 of condoms in US correctional facilities.
  33. The effects of individualand community-level knowledge, beliefs, and fear on stigmatization of people living with HIV/AIDS in China.
  34. The efficacy of female condom skills training in HIV risk reduction among women: a randomized controlled trial.
  35. (2002). The impact of the work environment on condom use among female bar workers in the Philippines. Health Educ Behav.
  36. (2005). Tiglao TV. HIV/AIDS prevention among the male population: results of a peer education program for taxicab and tricycle drivers in the Philippines. Health Educ Behav.
  37. (2002). Validating the effects of social desirability on self-reported condom use behavior among commercial sex workers. AIDS Educ Prev.