Understanding the Relationship Between Female Sex Workers and Their Intimate Partners: Lessons and Initial Findings From Participatory Research in North Karnataka, South India.

While traditional HIV prevention programs with female sex workers (FSWs) in Karnataka, India, have focused on reducing HIV transmission between FSWs and clients through increased condom use, these programs have not fully addressed the transmission risk between FSWs and their nonpaying intimate partners (IPs). Condom use is infrequent and violence is recurrent in these relationships: Furthermore, there is little evidence on the precise nature of FSW-IP relationships. Our study addresses this knowledge gap to inform HIV programs targeted at FSWs. A series of workshops, using participatory tools, was held to explore FSW-IP relationships; 31 FSWs and 37 IPs participated. Three aspects of FSW-IP relationships were examined: how FSWs and IPs understand and interpret their relationships, factors influencing condom use, and the role of violence and its consequences. FSWs wish to be perceived as their IPs' wives, while IPs expect their FSW partners to accept their dominance in the relationship. Nonuse of condoms signals fidelity and elevates the status of the relationship almost to that of marriage, which helps FSWs enter the category of "good" (married) women. Tolerating and accepting violence in these relationships is normative, as in other marital relationships; IPs justify violence as necessary to establish and maintain their power within the relationship. Both FSWs and IPs value their relationships despite the high degree of risk posed by low condom use and high levels of violence. Implications for program design include addressing current norms around masculinity and gender roles, and improving communication within relationships

Changes in Family-Level Attitudes and Norms and Association with Secondary School Completion and Child Marriage Among Adolescent Girls: Results from an Exploratory Study Nested Within a Cluster-Randomised Controlled Trial in India.

We evaluated the impact of Samata, a 3-year multilayered intervention among scheduled caste/scheduled tribe (SC/ST) adolescent girls in rural northern Karnataka, on family-level (parents or guardian) attitudes and direct and indirect norms related to child marriage and girl's education. Endline data from 1840 family members were used to assess the effect of Samata on attitudes and norms related to schooling and child marriage, while data from 4097 family members (including 2257 family members at baseline) were used to understand the shifts in attitudes and norms over the period 2014-2017. Overall, we found that the programme had little impact on family-level attitudes and norms. However, there were shifts in some attitudes, norms and perceived sanctions between baseline (when girls were aged 13-14 years) and endline (when girls were aged 15-16 years), with some becoming more progressive (e.g. direct norms related to child marriage) and others more restrictive (e.g. norms around girls completing secondary education and norms related to child marriage and educational drop-out, blaming girls for eve teasing and limiting girls' mobility so as to protect family honour). Moreover, non-progressive norms related to marriage and education were strongly associated with child marriage and secondary school non-completion among adolescent girls in this rural setting. Norms hypothesised to be important for marriage and schooling outcomes were indeed associated with these outcomes, but the intervention was not able to significantly shift these norms. In part, this may have been due to the intervention focusing much of its initial efforts on working with girls alone rather than family members, the relevant reference group. Future interventions that seek to affect norms should conduct formative research to clarify the specific norms affecting the outcome(s) of interest; likewise, programme planners should ensure that all activities engage those most influential in enforcing the norm(s) from the beginning. ClinicalTrials.gov registration number: NCT01996241

Mental health, physical impairment and violence among FSWS in North Karnataka, South India: a story of intersecting vulnerabilities

AimsThis study examines the prevalence and associations between recent violence experience, mental health and physical health impairment among Female Sex Workers (FSWs) in north Karnataka, India.BackgroundMulti-morbidity, in particular the overlap between physical and mental health problems, is an important global health challenge to address. FSWs experience high levels of gender-based violence, which increases the risk of poor mental health, however there is limited information on the prevalence of physical health impairments and how this interacts with mental health and violence.MethodWe conducted secondary analysis of cross-sectional quantitative survey data collected in 2016 as part of a cluster-RCT with FSWs called Samvedana Plus. Bivariate and multivariate analyses were used to examine associations between physical impairment, recent (past 6 months) physical or sexual violence from any perpetrator, and mental health problems measured by PHQ-2 (depression), GAD-2 (anxiety), any common mental health problem (depression or anxiety), self-harm ever and suicidal ideation ever.Result511 FSWs participated. One fifth had symptoms of depression (21.5%) or anxiety (22.1%), one third (34.1%) reported symptoms of either, 4.5% had ever self-harmed and 5.5% reported suicidal ideation ever. Over half (58.1%) reported recent violence. A quarter (27.6%) reported one or more chronic physical impairments. Mental health problems such as depression were higher among those who reported recent violence (29%) compared to those who reported no recent violence (11%). There was a step-wise increase in the proportion of women with mental health problems as the number of physical impairments increased (e.g. depression 18.1% no impairment; 30.2% one impairment; 31.4% ≥ two impairments). In adjusted analyses, mental health problems were significantly more likely among women who reported recent violence (e.g. depression and violence AOR 2.42 (1.24–4.72) with rates highest among women reporting recent violence and one or more physical impairments (AOR 5.23 (2.49–10.97).ConclusionOur study suggests multi-morbidity of mental and physical health problems is a concern amongst FSWs and is associated with recent violence experience. Programmes working with FSWs need to be mindful of these intersecting vulnerabilities, inclusive of women with physical health impairments and include treatment for mental health problems as part of core-programming.Samvedana Plus was funded by UKaid through Department for International Development as part of STRIVE (structural drivers of HIV) led by London School of Hygiene and Tropical Medicine and the What Works to Prevent Violence Against Women and Girls Global Programme led by South African Medical Research Council</jats:sec

The Samata intervention to increase secondary school completion and reduce child marriage among adolescent girls: results from a cluster-randomised control trial in India.

BACKGROUND: Secondary education and delayed marriage provide long-term socio-economic and health benefits to adolescent girls. We tested whether a structural and norms-based intervention, which worked with adolescent girls, their families, communities, and secondary schools to address poverty, schooling quality and gender norms, could reduce secondary school drop-out and child marriage among scheduled-caste/scheduled-tribe (SC/ST) adolescent girls in rural settings of southern India. METHODS: 80 of 121 villages in Vijayapura and Bagalkote districts, Karnataka State, were randomly selected (control?=?40; intervention?=?40). All 12-13 year-old SC/ST girls in final year of primary school (standard 7th) were enrolled and followed for 3 years (2014-2017) until the end of secondary school (standard 10th). Primary trial outcomes were proportion of girls who completed secondary school and were married, by trial end-line (15-16 years). Analyses were intention-to-treat and used individual-level girl data. RESULTS: 92.6% (2275/2457) girls at baseline and 72.8% (1788/2457) at end-line were interviewed. At end-line, one-fourth had not completed secondary school (control?=?24.9%; intervention?=?25.4%), and one in ten reported being married (control?=?9.6%; intervention?=?10.1%). These were lower than expected based on district-level data available before the trial, with no difference between these, or other schooling or sexual and reproductive outcomes, by trial arm. There was a small but significant increase in secondary school entry (adjusted odds ratio AOR?=?3.58, 95% confidence interval CI?=?1.36-9.44) and completion (AOR=1.54, 95%CI?=?1.02-2.34) in Vijayapura district. The sensitivity and attrition analyses did not impact the overall result indicating that attrition of girls at end-line was random without much bearing on overall result. CONCLUSIONS: Samata intervention had no overall impact, however, it added value in one of the two implementation districts- increasing secondary school entry and completion. Lower than expected school drop-out and child marriage rates at end-line reflect strong secular changes, likely due to large-scale government initiatives to keep girls in school and delay marriage. Although government programmes may be sufficient to reach most girls in these settings, a substantial proportion of SC/ST girls remain at-risk of early marriage and school drop-out, and require targeted programming. Addressing multiple forms of clustered disadvantage among hardest to reach will be key to ensuring India "leaves no-one behind" and achieves its gender, health and education Sustainable Development Goal aspirations. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT01996241

Understanding out-migration among female sex workers in South India

Background: Migrant sex workers are known to be vulnerable to HIV. There is substantial female sex worker (FSW) mobility between the borders of Maharashtra and Karnataka, but little programming emphasis on migrant FSWs in India. We sought to understand the individual/cultural, structural, and contextual determinants of migration among FSWs from Karnataka. Methods: A cross-sectional face-to-face interview of 1,567 FSWs from 142 villages in 3 districts of northern Karnataka, India was conducted from January to June 2008. Villages having 10+ FSWs, a large number of whom were migrant, were selected following mapping of FSWs. Multinomial logistic regression was conducted to identify characteristics associated with migrant (travelled for ≥ 2 weeks outside the district past year) and mobile (travelled for \u3c 2 weeks outside the district past year) FSWs; adjusting for age and district. Results: Compared with nonmigrants, migrant FSWs were more likely to be brothel than street based (Adjusted Odds Ratio (AOR): 5.7; 95% confidence interval: 1.6–20.0), have higher income from sex work (Adjusted Odds Ratio (AOR): 42.2; 12.6–142.1), speak \u3e2 languages (AOR: 5.6; 2.6–12.0), have more clients (AOR_per client: 2.9; 1.2–7.2), and have more sex acts per day (AOR_per sex act: 3.5; 1.3–9.3). Mobile FSWs had higher income from sex work (AOR: 13.2; 3.9–44.6) relative to nonmigrants, but not as strongly as for migrant FSWs. Conclusion: Out-migration of FSWs in Karnataka was strongly tied to sex work characteristics; thus, the structure inherent in sex work should be capitalized on when developing HIV preventive interventions. The important role of FSWs in HIV epidemics, coupled with the potential for rapid spread of HIV with migration, requires the most effective interventions possible for mobile and migrant FSWs

Prevalence and correlates of psychological distress among 13–14 year old adolescent girls in North Karnataka, South India: a cross-sectional study

Background: Mental health disorders among adolescents have emerged as a major public health issue in many low and middle-income countries, including India. There is a paucity of research on the determinants of psychological distress, particularly among the poorest girls in the poorest communities. The purpose of this study was to assess the prevalence and correlates of different indicators of psychological distress among 13–14 year old low caste girls in rural, south India. Methods: Cross-sectional survey of 1191 low caste girls in two districts in north Karnataka, conducted as part of a cluster randomised-control trial. Bivariate and multivariate logistic regression analysis assessed correlates of different indicators of psychological distress. Results: More than one third of girls (35.1%) reported having no hope for the future. 6.9% reported feeling down, depressed or hopeless in the past 2 weeks. 2.1% reported thinking they would be better off dead or of hurting themselves in some way in the past 2 weeks. 1.6% reported sexual abuse, 8.0% rrecent eve teasing and 6.3% having no parental emotional support. Suicidal ideation was independently associated with sexual abuse (AOR 11.9 (3.0–47.0)) and a lack of parental emotional support (AOR 0.2 (0.1–0.5)). Feeling down, depressed or hopeless was independently associated with recent eve-teasing (AOR 2.9 (1.6–5.4)), a harassing or abusive school environment (AOR 3.9 (1.8–8.2)), being frequently absent (AOR 2.8 (1.5–5.5)) or having dropped out of school (AOR 2.1 (1.0–4.3)), and living in Vijayapura district (AOR 2.5 (1.6–4.1)). Having no hope for the future was independently associated with a range of factors, including recent “eve-teasing” (AOR 1.5 (1.0–2.4)), being engaged (AOR 2.9 (0.9–9.7)), not participating in groups (AOR 0.5 (0.4–0.6)) and a lack of emotional support (AOR 0.6 (0.4–0.7)). Conclusions: Rather than being a time of optimism, a third of low caste girls in rural north, Karnataka have limited hope for the future, with some contemplating suicide. As well as having important development benefits, interventions that address the upstream structural and gender-norms based determinants of poor mental health, and provide adolescent services for girls who require treatment and support, should have important benefits for girls’ psychological wellbeing. Trial registration: Prospectively registered at ClinicalTrials.GovNCT01996241 . November 27, 2013Medicine, Faculty ofNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India

Abstract Background India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes. Methods The study was conducted during 2017–18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis. Results Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum. Conclusions The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level

Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India

Abstract Background Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations. Methods Samvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these ‘intimate’ relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017. Conclusions This is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence. Trial registration Clinical Trials NCT02807259 Jun 24 2016 (retrospectively registered)

Media, nationalism, and the body: Exploring masculinities, male partner violence, and HIV vulnerability among female sex workers in northern Karnataka, India

Public health and media discourses on men and HIV prevention in India have largely focused on changing knowledge, attitudes and risk behaviour pertaining to condom use and safe sex. Little attempt has been made towards intervening in areas such as masculinity, dominant gender norms and intimate partner violence (IPV) that have been shown to have a direct link to HIV prevalence. In this paper, drawing on findings from an ethnographic study in northern Karnataka (India), we show how socio-political and communicative contexts influence and perpetuate violent behaviours by men in intimate relationships with female sex workers (FSW). We argue that constructions of masculinity, the stereotypes of which are reinforced through contemporary media, and movies, are intricately linked with processes of nationalism and play out in forms of chauvinism among working-class men. Violence, celebrated through various patriarchal discourses, legitimises and reinforces gender ideals that govern the private lives of men and their female intimate partners. This study provides a complex and nuanced understanding of structural factors that lead to IPV against FSWs and offers implications for HIV intervention planning in the region and beyond