Coast, Ernestina

Puradiredja, Dewi Ismajani

Sear, Rebecca

English

LSE Research Online

  Dewi Ismajani Puradiredja, Ernestina Coast and Rebecca Sear Why do female sex workers in Indonesia not use condoms?: a mixed methods study of the heterogeneous contexts of condom use Conference Item (paper)     Original citation: Puradiredja, Dewi Ismajani and Coast, Ernestina and Sear, Rebecca (2008) Why do female sex workers in Indonesia not use condoms?: a mixed methods study of the heterogeneous contexts of condom use. In: European Population Conference, 9-12 July 2008, Barcelona, Spain. This version available at: http://eprints.lse.ac.uk/42041/  Available in LSE Research Online: May 2012  © 2012 The Authors  LSE has developed LSE Research Online so that users may access research output of the School. Copyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in LSE Research Online to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain. You may freely distribute the URL (http://eprints.lse.ac.uk) of the LSE Research Online website.     EXTENDED ABSTRACT  1 Why Do Female Sex Workers in Indonesia Not Use Condoms: A Mixed Methods Study of the Heterogeneous Contexts of Condom Use  Dewi Ismajani Puradiredja, Ernestina Coast and Rebecca Sear London School of Economics and Political Science, UK  Introduction Unprotected heterosexual transactional sex is one of the major drivers of the HIV epidemic in Indonesia. Indonesia’s efforts have focused on increasing AIDS awareness and access to male condoms among sub-populations at high risk of sexually transmitted HIV infection, such as female sex workers (FSWs).  However, second-generation HIV surveillance has shown that even if Indonesian FSWs are aware of HIV/AIDS and the benefits of using condoms, the majority continue to use condoms inconsistently, if at all (BSS 1996-2000; BSS 2001-2005) (1). While survey data are available on HIV/STI prevalence and awareness, levels of condom use and some basic socio-demographic indicators among urban FSWs, little is known about the context of sex work and its interplay with condom (non-)use among sub-groups of Indonesian FSWs, particularly rural FSWs.  This study uses a comparative rural-urban research design and a mixed methods approach to collect and analyse qualitative and quantitative data related to condom use in the context of transactional sex by FSWs in Indonesia. Firstly, this study identifies which factors inhibit condom use with clients among FSWs with different background and individual characteristics, and sex work settings. Secondly, it investigates the ways in which the different sex work settings and individual characteristics interrelate with condom (non-)use by FSWs. A novel three-staged purposive sampling technique enabled the inclusion of notoriously under-researched sub-populations, such as rural FSWs and FSWs in urban slum areas with high rates of crime and violence. Reasons for condom non-use are compared between the different study populations.   Methods   Study sites The two primary research sites, the Capital District of Jakarta and the District of Indramayu in the West of Java, were selected according to the intensity of transactional sex work activity and to represent two different geographical contexts, one urban and one rural. The sites were selected with reference to existing research and secondary data from national HIV/AIDS surveillance, and                                                  1 BSS (1996-2000). Behavioural Surveillance Survey. Centre for Health Research University of Indonesia supported by The Ministry of Health, Republic of Indonesia under the HIV/AIDS Prevention Project (HAPP)/Family Health International. Jakarta. Indonesia; BSS (2001-2005). Behavioural Surveillance Survey. Directorate of Communicable Disease Control and Environmental Health, Ministry of Health and Central Bureau of Statistics. Jakarta. Indonesia  EXTENDED ABSTRACT  2 in consultation with key informants at local research institutes and non-governmental organisations (NGOs).   The study populations   The study populations were selected to represent, to the extent possible, the following target groups and their respective sex work contexts: 1) direct FSWs and 2) indirect FSWs (2), differentiated by venue and non-venue based sex work, by socio-economic status (i.e. low, middle, and high income scale) and by rural and urban geographical location. Particular priority was being given to include sub-groups in sites, which have thus far been mostly excluded from national surveillance and existing research, such as rural FSWs.  Sample size and sampling strategy The total survey sample (n=310) includes 101 urban indirect FSWs, 83 urban direct FSWs, and 126 rural FSWs. In the context of this study, the common problems associated with the conventional probablistic sampling of hard-to-reach populations that engage in illegal or illicit behaviours, such as difficulties in constructing a reliable sampling frame, were addressed by purposively selecting the study sample in three stages. The first stage involved formative mapping exercises with reference to maps and listings from secondary sources, in order to identify and confirm sites where different types of FSWs solicit and to become familiar with their work settings. The second stage involved the purposive selection of locations during pre-set time intervals and the random selection of survey respondents from each time-location unit. Selection criteria included: type of sex work setting and socio-economic classifications. The third stage involved the purposive selection of the qualitative sub-sample (n=12) from the survey sample following the inductive principles of Grounded Theory. The objective was to sample for heterogeneity, and thus respondents were chosen to maximise the range of perspectives investigated in the study. Selection criteria included: type of sex work setting, socio-economic background characteristics, pre-existing HIV/AIDS and condom awareness, and consent to having the interview recorded.   Data The self-reported quantitative data collected include knowledge of HIV/AIDS and STIs and means of their prevention, reproductive and (transactional) sexual behaviour and condom use, and a social-cognitive health-specific self-efficacy measure tailored to condom use by FSWs with their clients. In addition, comprehensive data were collected on respondents’ demographic and socio-economic characteristics. Qualitative data were collected on the type of sex work setting,                                                  2 Direct FSWs: Women who openly operate as commercial sex workers, such as in red light districts, brothels, street or rice fields. Indirect FSWs: Women whose involvement in commercial sex work is disguised and who are often officially employed in a number of identifiable occupations, such as in massage parlours, karaoke bars or spas. EXTENDED ABSTRACT  3 including work organisation, atmosphere, and social relationships; general and HIV-related risk perceptions and prevention; attitudes towards condoms and their use; and situational accounts of condom use negotiation by FSWs with their clients. Inhibiting reasons for condom use by FSWs with their clients were explored by accounting for respondents’ HIV/AIDS awareness; their demographic and socio-economic background characteristics; variations in sex work setting, including social relationships; and situational, psychosocial and personal factors.   Analyses Descriptive statistics will be presented to establish a demographic and socio-economic profile of the sub-groups under comparison, and their respective levels of HIV/AIDS awareness and frequency of condom use with their clients. Logistic regression modeling will be used to investigate the significance of association between HIV-related sexual behaviours, demographic, socio-economic and psychosocial factors and the binary outcome variable condom use/non-use, before and after controlling for HIV/AIDS awareness. In addition, using NUD*IST software, a comparative qualitative data analysis of contexts, and the properties of condom use and its inhibitors among all in-depth interview respondents, and focus coding of the emerging themes – in what ways different work settings interrelate with condom non-use among FSWs with different background characteristics and personalities – will be presented. .   Key findings and contributions Findings suggest that compared with urban indirect venue-based FSWs, rural and urban direct non-venue and brothel-based FSWs are less likely to be aware of HIV/AIDS and to use condoms. Their rationality in relation to condom use is primarily informed by economic pressure, gender power relationships, social marginalisation and work settings that are more prone to the risks of violence and harassment. Yet, HIV/AIDS and condom awareness by and of themselves are not guarantors for consistent condom use. While urban indirect venue-based FSWs reported higher levels of HIV/AIDS awareness and condom use, their ability to consistently use condoms with clients shows to be obstructed by factors, such as an unsupportive sex workplace management, type and pricing of transactional sex services, off-work-site transactions, and familiarity with clients. In addition, among all groups under comparison condoms are far more likely to be used during vaginal sex with clients as opposed to oral and anal sex. HIV prevention/intervention programmes have to account for the heterogeneity of FSWs and the complex interplay between their individual agency and their work contexts in order to effectively address their differing needs. In methodological terms, this study provides an innovative strategy for the sampling of a hard-to-reach population, and demonstrates the importance of a mixed methods approach when undertaking a differentiated and complete socio-demographic description of, and explanation for, condom (non-) use by female sex workers with their clients.  EXTENDED ABSTRACT  4 Acknowledgements Funding: Central Research Fund (CRF), Sir Richard Stapley Educational Trust (SRSET); Supervision: Ernestina Coast, Rebecca Sear; Research assistance and data collection: Diah Ekawati, Inu Dwiarto, Midha Putri Ginanjar, Boedhi Adhitya Bhakti, Widya Kinanti Larasati, Citra Rofikasari, Melisa Putri Susanto; Field research support (in alphabetical order): Mohammad Azis, Ahmad Caesar, Rita Damayanti, Amry Ismail, Bang Kozel, Sabarinah Prasetyo, Yudarini Priotomo, Agus Dwi Setiawan, Ferdinand P. Siagan, Heru Suparno at the Centre for Health Research at University of Indonesia (CHR-UI); Leny Agustina, Hasbi Ashdiqy, Sanding Bayu, James Johnson, Karyono, Martin Nahruirfan, Bambang Prianto, Yenni Siswantini, Riyadus Solihin, Chandra Sutanto, Aang Sutrisna at Family Health International (FHI) Indonesia; Nur Aziza, Azkanissa, Surya Meidi Darma, Irfan Hardiansyah, Azhari Irdah, Narendra Narotama, Parama, Sallynita, Betty Kemal Taruc, Tri Budi Utami, Winda Wiwi at KAPETA Foundation; Hassanudin, Andri Martin, Yogi Prayoga, Sinta Rahmasari, Yudi Supriadi at PKBI-Oxfam-Novib; Mbak Ayu at Putri Mandiri; Mbak Ade, Mbak Aulia, Chandra Chaniago, Firman Lubis, Yani Mulyani, Mbak Nita, Mbak Nofi, Nono Taryono and Ibu Marti, Wisnu Prasadja, Roswildania, Mas Samsul, Adi Sasongko, Bapak Sukim, Mbak Wiwi, Ratih Wahyuningastuti, Bang Zenal at Yayasan Kusuma Buana (YKB) and Yayasan Kusuma Bongas; the first author would also like to thank Andrew Phillips, Fiona Lampe, and Wendy Bannister, Loveleen Bansi, Clinton Chaloner, Alessandro Cozzi-Lepri, Zoe Fox, Elaine Harris, Teresa Hill, Rebecca Lodwick, Amanda Mocroft, Joanne Reekie, Caroline Sabin, Colette Smith of the HIV Epidemiology and Biostatistics Group at Royal Free and University College Medical School, London, UK; Axel Stamer, Bapak Kamto and the Puradiredja family.    

Why do female sex workers in Indonesia not use condoms?: a mixed methods study of the heterogeneous contexts of condom use

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