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 THE STIGMA OF SEX WORK AND ASSOCIATED HEALTH CARE

SERVICES FROM THE PERSPECTIVES OF SEX WORKERS, NURSES,

AND NURSING STUDENTS IN HONG KONG: THE DEVELOPMENT OF

AN INTERVENTION TO REDUCE STIGMA TOWARDS SEX WORKERS

AMONG NURSES

MA HAIXIA

PhD

The Hong Kong Polytechnic University

2020

i
 The Hong Kong Polytechnic University

School of Nursing

The stigma of sex work and associated health care services from the

perspectives of sex workers, nurses, and nursing students in Hong Kong: the

development of an intervention to reduce stigma towards sex workers among

nurses

Ma Haixia

A thesis submitted in partial fulfillment of the requirements for the degree of

Doctor of Philosophy

August, 2019

ii
 CERTIFICATE OF ORIGINALITY

I hereby declare that this thesis is my own work and that, to the best of

my knowledge and belief, it reproduces no material previously

published or written, nor material that has been accepted for the award

of any other degree or diploma, except where due acknowledgements

has been made in the text.

(Signed)

Ma Haixia (Name of student)

iii
 Abstract of dissertation entitle:

―The stigma of sex work and associated health care services from the perspectives of
sex workers, nurses, and nursing students in Hong Kong: the development of an
intervention to reduce stigma towards sex workers among nurses‖
Submitted by Ma Haixia
for the degree of Doctor of Philosophy at The Hong Kong Polytechnic University

Background: Timely and equal access to health is considered as a basic human right.

Despite multiple healthcare needs and free sexual and reproductive health care

services in Hong Kong, many sex workers remain reluctant to seek timely treatment.

A synthesis of the relevant literature suggests that multiple barriers could hinder sex

workers from accessing health care services, and the negative attitudes of healthcare

providers are a major deterrent to sex workers in accessing health care services.

However, there has been no study focusing on the experiences of sex workers with

accessing health care services in Hong Kong. Also, there is little understanding of

the perceptions of nurses and nursing students in of their role in providing non-

discriminatory care to sex workers.

Aims: The study aimed to explore the stigma of sex work and associated health care

services from the perspectives of sex workers, nurses, and nursing students in Hong

Kong, and to develop an intervention to reduce stigma towards sex workers among

nurses.

Methods: A series of studies were conducted to identity the stigma of sex work and

associated health care services from the perspectives of sex workers, nurses, and

nursing students. It contained three components: 1) semi-structured focus group

discussions with nurses; 2) semi-structured individual interviews with female sex

iv
workers (FSWs); 3) a cross-sectional survey among undergraduate nursing students.

Based on the review of the literature and the local evidence, the Medical Research

Council (MRC) framework guided the development of a preliminary conceptual

framework and a complex intervention to reduce stigma towards sex workers among

nurses in Hong Kong.

Results: Overall, the female sex workers could access to the health care services in

Hong Kong. However, stigma remains the key barrier to their seeking timely

professional help, fully disclosing their secret of being involved in sex work, and

receiving comprehensive health care services.

Meanwhile, given that sex-related topics are still a taboo in Chinese

communities, the health needs and stigmatization of sex workers are not topics that

have been included in nursing education and clinical practices in Hong Kong. The

findings from qualitative interview study of 36 nurses and a cross-sectional study of

317 nursing students suggest that nurses and nursing students have insufficient

knowledge or are misinformed about sex workers and the sex industry, and hold

prejudicial attitudes toward sex workers. But they will comply with the professional

code of ethics in providing care to patients whom they suspect to be sex workers.

Conclusion: This study contributes to a better understanding of the stigma of sex

work and associated health care services in Hong Kong. Nurses and nursing students

held strong, but ambivalent, personal attitudes toward sex workers. This study also

contributes to increasing awareness of, and respect for, the human right of FSWs to

receive non-discriminatory health services. Reducing sex work-related stigma among

v
healthcare providers, including nursing professionals and students, is critical to

addressing health disparities between sex workers and the general population.

vi
 Publications arising from the thesis

Journal publications

1. Ma, P. H., Chan, Z. C., & Loke, A. Y. (2017). The Socio-Ecological Model

Approach to Understanding Barriers and Facilitators to the Accessing of Health

Services by Sex Workers: A Systematic Review. AIDS and Behavior, 21(8),

2412-2438.

2. Ma, P. H., Chan, Z. C., & Loke, A. Y. (2018). Self-Stigma Reduction

Interventions for People Living with HIV/AIDS and Their Families: A

Systematic Review. AIDS and Behavior, 1-35.

3. Ma, P. H., Chan, Z. C., & Loke, A. Y. (2018). A Systematic Review of the

Attitudes of Different Stakeholders Towards Prostitution and Their Implications.

Sexuality Research and Social Policy, 15(3), 231-241.

4. Ma, P. H., Chan, Z. C., & Loke, A. Y. (2019). Conflicting identities between sex

workers and motherhood: A systematic review. Women & health, 59(5), 534-557.

5. Ma, H & Loke, A.Y. (2019) A qualitative study into female sex workers‘

experience of stigma in the health care setting in Hong Kong. International

Journal for Equity in Health, 18(1), 175.

6. Ma, H., & Loke, A. Y. (2020). Knowledge of, attitudes toward, and willingness

to care for female sex workers: differences between general and mental health

nursing student. Journal of professional nursing (In press).

Manuscript under review

1. Ma, P. H., & Loke, A. Y. (2019). A scoping review of an HIV/AIDS-related

stigma-reduction intervention for professionals and students from health-related

vii
 disciplines – Implications for stigma-reduction interventions related to sex work.

(International Journal of Sexual Health, major revision).

2. Ma, P. H., & Loke, A. Y. (2019). Caring for female sex workers: a qualitative

study on perspectives of practicing nurses in Hong Kong. Under reviwe at AIDS

Care Psychology, Health & Medicine Vulnerable Children and Youth Studies.

(AIDS Care, submitted 22nd Mar, 2019).

Conference presentations

1. Ma, P. H., Chan, Z. C., & Loke, A. Y. (2016). The experience of motherhood

among female sex workers: a systematic review. Optimizing Healthcare Quality

Conference. Chiang Mai, Thailand. 22nd June to 24th June, 2016

2. Ma, P. H. & Loke, A. Y. A qualitative study of nurses‘ perspectives on female

sex workers‘ health. 22nd East Asia of Nursing Scholar (EAFONS), Singapore,

10th to 11th January, 2019.

3. Ma, Haixia & Loke, A.Y. Knowledge of, attitudes toward, and willingness to

care for female sex workers: differences between general and mental health

nursing student. N-nergizing Nursing Profession for NCD Challenges (N3

Nursing Conference), Bangkok, Thailand, 8th to 10th, 2020.

viii
 Acknowledgements

First of all, I would like to thank my chief supervisor, Prof. Alice Yuen LOKE, for

her unfailing support, teaching and encouragement to me throughout the study. I am

deeply grateful to have her professional guidance, unwavering support, and

consistent encouragement in my Ph.D. study. Her endless dedication to students

inspired my passion for this study throughout the years. Her influence on me is not

only academic, but also conducting oneself in society. I learned from her a never-

give-up spirit, so that my study can be completed with quality and on time.

I would like to thank Dr. Doris Leung, Dr. Dan Bressington, Dr. Angela Chan, Dr.

Vivian Ngai, Dr. Jessica Li, Ms. Kitty Wong, Mr. Edmond Tong, for their valuable

comments on the validation of the measurements. And I would like to thank the

program leaders of the School: Dr. Yim Wah Mak, Dr. Sau Fong Leung, Dr. Cheung

Kin, Dr Cynthia Wu, Dr. Mimi Tse, Ms. Kitty Wong, Dr. Wai Kit Wong, for their

support in data collection.

I would also like to thank the Action for Reach Out, the JJJ association, and the

Midnight blue, for their assistances in recruiting sex workers. They helped me to

open a door to access to the sex worker. In addition, I would especially like to thank

Coco, who herself has depression. Every time she had to have a lot of courage to

force herself to go out and took me to the ―one-woman brothel‖ for conducting my

interview. I hope she can get better soon.

I would like to thank the all the nurses and nursing students for their valuable time to

participate in this study. Without their participation, this study would not have been

ix
possible. I would also like to thank the sex workers. I not only gained trust but also

gained friendship. I can get their warmth even in times of difficulty. They are a group

of lovely people.

I would like to thank my school for providing me with a diverse learning

environment. I am grateful to have so many teachers and friends, especially the

classmates under the same supervisor, to listen to me and support me during my

difficult time. I would also like to thank my peers, Dr. Alex Vu, Ms. Anna, for

supporting each other and cheering each other over the past few years. I am

especially grateful to my mentor, Dr. Connie Chong, her passion for research always

influence me.

Finally, I would like to thank my family, my parents, my sisters, and my husband, for

giving me support, encouragement and the greatest freedom. Especially thanks to my

husband and my two lovely children. Although I needed to work overtime every

weekend and the responsibility of taking care for the child was given to my husband,

he had never complained. Moreover, I would like to say sorry to my children

because I always missed the parent-teacher meeting and even my daughter‘s dance

competition. How many weekends, my daughter wanted to come to my office but I

refused, because it would affect me. To my son, I am deeply blamed because he has a

stomachache for almost two years but I had no time to take care of him well. I hope I

can manage the dual roles between the jobs as a researcher and a mother in the future.

x
 TABL OF CONTENTS

CERTIFICATE OF ORIGINALITY ................................................................................ iii

Abstract ............................................................................................................................ iv
Publications arising from the thesis ................................................................................ vii
Acknowledgements .......................................................................................................... ix
Tabl of contents ................................................................................................................ xi
List of tables ................................................................................................................. xviii
List of figures ................................................................................................................. xix
List of abbreviations ........................................................................................................ xx

PART I INTRODUCTION AND THE ADOPTED MEDICAL RESEARCH

COUNCIL (MRC) FRAMEWORK
Chapter 1 Introduction
1.1. Research background ................................................................................................. 3
1.1.1. Sex workers defined ................................................................................... 3
1.1.2. Types of sex work ...................................................................................... 4
1.1.3. Prevalence of sex workers .......................................................................... 4
1.1.4. Occupational health and safety of female sex workers .............................. 5
1.1.5. Reluctant of sex workers to seek timely treatment .................................... 6
1.1.6. Stigma is a barrier for sex workers in accessing health care services ........ 6
1.1.7. Preparing nurses to care for sex workers ................................................... 7
1.2. Research aims and objectives..................................................................................... 9
1.3. Project significance and value .................................................................................... 9
1.4. The adopted Medical Research Council (MRC) framework ................................... 10
1.4.1. The developing, evaluating, and implementing process of a complex
intervention ........................................................................................................ 10
1.4.2. Studies conducted in developing an intervention to reduce stigma towards
sex workers among nurses in Hong Kong.......................................................... 12
1.5. Outline of the thesis ................................................................................................. 12

PART II IDENTIFYIGN THE EVIDENCE BASED IN THE

PROCESS OF MRC FRAMEWORK: REVIEWS OF LITERATURE
Chapter 2 Review of literature (I) Sex workers and motherhood
2.1. My experience in working with sex workers and initial intention for my PhD

xi
study ................................................................................................................................ 18
Conflicting identities between sex workers and motherhood: A systematic review ....... 20
2.2. Background of the review ........................................................................................ 20
2.3. Methods .................................................................................................................... 21
2.3.1. Search strategies and study selection process .......................................... 21
2.3.2. Inclusion and exclusion criteria ............................................................... 22
2.3.3. Assessing the quality of the methodology................................................ 22
2.3.4. Data Synthesis .......................................................................................... 22
2.4. Results ...................................................................................................................... 23
2.4.1. Characteristics of the selected studies ...................................................... 25
2.4.2. Assessing the quality of the included studies ........................................... 25
2.4.3. Findings from qualitative studies ............................................................. 26
2.4.4. Differences in findings across countries .................................................. 29
2.4.5. Findings from quantitative studies ........................................................... 29
2.5. Discussion ................................................................................................................ 30
2.6. Limitations ............................................................................................................... 32
2.7. Summary .................................................................................................................. 33
2.8. Recommendations for future research ..................................................................... 33

Chapter 3 Review of literature (II) Attitudes of Different Stakeholders towards

sex workers
3.1. Background of the review ........................................................................................ 36
3.2. Aim of this review .................................................................................................... 38
3.3. Methods .................................................................................................................... 39
3.3.1. Search strategies and study selection process .......................................... 39
3.3.2. Inclusion and exclusion criteria ............................................................... 40
3.3.3. Assessing the quality of the included literature ....................................... 41
3.3.4. Data extraction ......................................................................................... 43
3.4. Results ...................................................................................................................... 43
3.4.1. Characteristics of the selected studies ...................................................... 43
3.4.2. Quality of the included literature ............................................................. 44
3.4.3. Attitudes toward sex workers ................................................................... 45
3.4.4. Attitudes toward prostitution laws ........................................................... 49
3.5. Discussion ................................................................................................................ 50
3.6. Limitations ............................................................................................................... 55

xii
3.7. Summary .................................................................................................................. 55
3.8. Recommendations for future research ..................................................................... 56

Chapter 4 Review of literature (III) Barriers and facilitators to the accessing of

health services by sex workers
4.1. Background of the review ........................................................................................ 58
4.2. Aim of this review .................................................................................................... 60
4.3. Methods .................................................................................................................... 61
4.3.1. Search strategies and study selection process .......................................... 61
4.3.2. Inclusion and exclusion criteria ............................................................... 62
4.3.3. Assessing the quality of the included literature ....................................... 64
4.3.4. Synthesis of the findings of the study ...................................................... 65
4.4. Results ...................................................................................................................... 66
4.4.1. Characteristics of the selected studies ...................................................... 66
4.4.2. Barriers to accessing health services ........................................................ 66
4.4.3. Facilitators to accessing health services ................................................... 71
4.5. Discussion ................................................................................................................ 75
4.6. Limitations ............................................................................................................... 79
4.7. Summary .................................................................................................................. 80

Chapter 5 The conceptualization of stigma and measurement of attitudes

toward sex workers
5.1. Introduction .............................................................................................................. 83
5.2. Stigma ...................................................................................................................... 83
5.2.1. Conceptualization of stigma..................................................................... 83
5.2.2. Levels of stigma and consequences ......................................................... 85
5.3. The stigma associated with sex work ....................................................................... 86
5.4 Recommendation for future interventions to reduce the stigma of sex work ........... 86

Chapter 6 Review of literature (IV) HIV/AIDS related stigma-reduction

intervention for professionals and students in health-related disciplines –
implications for stigma-reduction interventions related to sex work
6.1. Background of the review ........................................................................................ 90
6.2. Aim of the review ..................................................................................................... 90

xiii
6.3. A search for studies on interventions to reduce the stigmatizing attitudes of
health professionals towards sex work ............................................................................ 90
6.4. HIV stigma-reduction intervention programmes: implications for strategies for
interventions to reduce the stigma related to sex work ................................................... 95
6.5. Methods .................................................................................................................... 96
6.5.1. Search of the literature ............................................................................. 96
6.5.2. Inclusion and exclusion criteria ............................................................... 96
6.5.3. Appraisal of the quality of the included studies ....................................... 99
[Link] extraction and synthesis .................................................................. 100
6.6. Results .................................................................................................................... 101
6.6.1. Characteristics of intervention studies ................................................... 101
6.6.2. Characteristics of the interventions ........................................................ 102
6.6.3. Outcome-measuring instruments ........................................................... 106
6.6.4. Outcomes of the interventions ............................................................... 108
6.7. Discussion ...............................................................................................................113
6.8. Limitations of the study ..........................................................................................116
6.9. Summary .................................................................................................................116

Chapter 7 The stigma of sex work and associated health care professionals and
services (Summary of the literature reviews and identification of research gaps)
7.1. Main findings ..........................................................................................................118
7.2. Research gap identified .......................................................................................... 120
7.3. Aims and objectives of this study .......................................................................... 121
7.4. Summary ................................................................................................................ 122

PART III THE STUDY CONDUCTED

Chapter 8 Methodology
8.1. Methodology of the study ...................................................................................... 125
8.2. Sampling and recruitment ...................................................................................... 126
8.2.1. Phase one................................................................................................ 126
8.2.2. Phase two ............................................................................................... 127
8.2.3. Phase three ............................................................................................. 130
8.3. Ethical considerations ............................................................................................ 130
8.4. Data collection ....................................................................................................... 132

xiv
 8.4.1. Qualitative data ...................................................................................... 132
8.4.2. Quantitative data .................................................................................... 134
8.4.3. Sample size............................................................................................. 137
8.4.4. Validity and reliability of the questionnaire ........................................... 137
8.5. Data analysis .......................................................................................................... 140
8.5.1. Qualitative data analysis ........................................................................ 140
8.5.2. Quantitative data analysis ...................................................................... 143

Chapter 9 STUDY I Caring for female sex workers: a qualitative study on

perspectives of practicing nurses in Hong Kong
9.1. Results .................................................................................................................... 146
9.1.1. Characteristics of the participants .......................................................... 146
9.1.2. Themes of the study ............................................................................... 147
9.2. Discussion .............................................................................................................. 162
9.3. Implications ............................................................................................................ 165
9.4. Conclusion ............................................................................................................. 168

Chapter 10 STUDY II A qualitative study into female sex workers’ experience

of stigma in the health care setting in Hong Kong
10.1 Results ................................................................................................................... 170
10.1.1. Characteristics of the participants ........................................................ 170
10.1.2. Health conditions and accessing health care services .......................... 171
10.1.3. Themes of the study ............................................................................. 174
10.2. Discussion ............................................................................................................ 187
10.3. Implications .......................................................................................................... 189
10.4. Conclusion ........................................................................................................... 191

Chapter 11 STUDY III Knowledge of, attitudes towards, and willingness to care
for sex workers: differences between general and mental health nursing
students
11.1. Results .................................................................................................................. 193
11.1.1. Demographic characteristics of the participants .................................. 193
11.1.2. Knowledge and educational needs of the participants in relation to
caring for sex workers ...................................................................................... 195
11.1.3. Attitudes toward sex workers ............................................................... 197

xv
 11.1.4. Support for the human rights of sex workers ....................................... 199
11.1.5. Willingness to care for sex workers ..................................................... 201
11.1.6. Factors associated with attitudes toward sex workers .......................... 202
11.1.7. Factors associated with the willingness of students to care for sex
workers ............................................................................................................. 205
11.2. Discussion ............................................................................................................ 207
11.3. Implications .......................................................................................................... 214
11.4. Conclusion ............................................................................................................ 216

Chapter 12 IDENTIFYNG / DEVELOPING THEORY

A preliminary conceptual framework to understand the stigma toward sex
workers among nurses
12.1. The social ecological model identified from the qualitative study ...................... 218
12.2. Theories from the literature review ...................................................................... 219
12.3. A preliminary conceptual framework to understand the stigma toward sex
workers among nurses ................................................................................................... 221
12.4. Summary .............................................................................................................. 224

Chapter 13 MODELLING THE PROCESS AND OUTCOMES

The development of a complex intervention: reduce stigma towards sex workers
among nurses
13.1. The identified evidence ........................................................................................ 227
13.1.1. Evidence from the literature review ..................................................... 227
13.1.2. Evidence from a series of studies in Hong Kong ................................. 229
13.2. The proposed theory ............................................................................................. 230
13.3. The developed intervention to reduce stigma towards sex workers among
nurses ............................................................................................................................ 230
13.4 Summary ............................................................................................................... 238

PART IV CONCLUSIONS AND SUGGESTIONS FOR FUTURE RESEARCH

Chapter 14 Summary of the thesis
14.1 Introduction ........................................................................................................... 242
14.2 Main findings ........................................................................................................ 244
14.3 Implications for practice ....................................................................................... 247

xvi
14.4 Limitations ............................................................................................................ 248
14.5. Summary .............................................................................................................. 249
Appendices .................................................................................................................... 250
References ..................................................................................................................... 416

xvii
 LIST OF TABLES

Table Page

Table 9-1 Examples of meaning units, summarized meaning units, 159

sub-themes and themes

Table 10-1 Characteristics of the female sex workers (FSWs) and their 173

sex work

Table 10-2 Health status of the female sex workers and their utilization 174

of health care services

Table 10-3 Examples of meaning units, summarized meaning units, 185

sub-themes and themes

Table 11-1 Demographic characteristics of the participants (N=317) 194

Table 11-2 Knowledge or training of students related to care for sex 196

workers

Table 11-3 Attitudes of students toward sex workers 198

Table 11-4 Support of human rights of sex workers among students 200

(N=317)

Table 11-5 Willingness of nursing students to care for sex workers 201

(N=317)

Table 11-6 Stepwise linear regression to identify the correlating factors 204

of students‘ attitudes toward sex workers

Table 11-7 Stepwise linear regression of the correlating factors for the 206

willingness of nursing students to care for sex workers

Table 13-1 Main contents and delivering outline of the intervention 234

xviii
 LIST OF FIGURES

Figure Page

Figure 1-1 Key elements of the development and evaluation process 11

Figure 1-2 Process of MRC framework and studies conducted 15

corresponding to MRC framework in developing the

intervention

Figure 2-1 The flow diagram on identifying the literature 24

Figure 3-1 The flow diagram on identifying the literature 42

Figure 4-1 The Social Ecological Model 60

Figure 4-2 The flow diagram on identifying the literature 63

Figure 6-1 The flow diagram on identifying the literature 92

Figure 6-2 The flow diagram on identifying the literature 98

Figure 8-1 Steps taken and studies conducted corresponding to MRC 144

framework in developing a complex intervention

Figure12-1 Preliminary conceptual framework to understand stigma 222

toward sex workers among nurses

Figure 13-1 The key elements and focus of the intervention developed 233

based on a preliminary conceptual framework for nurses

Figure 14-1 Steps taken and studies conducted corresponding to MRC 243

framework

xix
 List of abbreviations

FSWs: female sex workers

HIV: human immunodeficiency virus

AIDS: acquired immune deficiency syndrome

STDs: sexually transmitted diseases

STI: sexually transmitted infection

xx
 PART 1

INTRODUCTION AND THE ADOPTED MEDICAL RESEARCH COUNCIL

(MRC) FRAMEWORK

1
 Chapter 1 Introduction

[Link] background

1.1.1. Sex workers defined

1.1.2. Types of sex work

1.1.3. Prevalence of sex workers

1.1.4. Occupational health and safety of female sex workers

1.1.5. Reluctant of sex workers to seek timely treatment

1.1.6. Stigma is a barrier for sex workers in accessing health care services

1.1.7. Preparing nurses to care for sex workers

1.1.8. Knowledge gap

[Link] aims and objectives

[Link] significance and value

[Link] of the thesis

2
1.1. Research background

1.1.1. Sex workers defined

Prostitution is the world‘s oldest profession. It has existed since the beginning of

history (Kipling, 1888). The term ―prostitute‖ generally refers to ―a woman over the

age of consent who willingly exchanges sexual services for money‖ (p.126)

(Llewellyn, Agu, & Mercer, 2008). Prostitution is associated with a stigmatizing

identity that defines people in a negative way (Parent, 2013). All forms of

engagement in the sex industry, such as an erotic dancer, a pornographic actor(ess),

or a ―call girl,‖ are all prostitution (Barry, 1996).

As opposed to the term ‗prostitute‘, the term ―sex worker‖ coined by

libertarian activists and sex workers themselves in the 1970s (Leigh, 1997), is

considered less stigmatizing (Parent, 2013). It is regarded as a neutral word that

describes the income-generating activities and emphasizes the occupation aspect of

this work (Leigh, 1997; Ross, Crisp, Månsson, & Hawkes, 2012). Now, ―sex worker‖

is commonly used in society, and is the terminology used by the World Health

Organization (WHO), and Joint United Nations Programme on HIV and AIDS

(UNAIDS, 2002).

The term ―sex worker‖ rather than ―prostitute‖ is used in the thesis, as it is

neutral, while the term ―prostitute‖ is only used where it is part of a direct quote. Sex

worker is defined as ―female, male and transgender adults and young people (aged

18–24) who receive money or goods in exchange for sexual services, either regularly

or occasionally, and who may or may not consciously define those activities as

income-generating‖ (p.3) (Overs, 2002; The Joint United Nations Programme on

HIV/AIDS, 2002).

3
1.1.2. Types of sex work

There are two types of sex work: direct and indirect sex work (Harcourt & Donovan,

2005). Direct sex work refers to sexual services in which the primary purpose of the

interaction is to exchange sex for money. In contrast, ‗indirect‘ sex work means that

sex work is not always the sole or primary source of income of individuals (Harcourt

& Donovan, 2005). Sex workers sell sexual services in a wide range of highly

diverse settings, such as brothels, massage parlor, saunas, street, night clubs, karaoke

bars, dance halls, hotels, beer girl, street vendors, and traders, etc. (Harcourt &

Donovan, 2005).

1.1.3. Prevalence of sex workers

The exact number of sex workers is difficult to estimate since they often work in

secrecy, and are hard to reach and highly mobilized. It was estimated that the

national prevalence of female sex workers (FSWs) ranged from 0.2% to 2.6% in

Asia, 0.4% to 4.3% in sub-Saharan Africa, 0.2% to 7.4% in Latin American, 0.4% to

1.4% in East Europe and 0.1% to 1.4% in West Europe (Vandepitte et al., 2006).

While sex workers are overwhelmingly female, the discussion in this thesis

mainly focuses on female sex workers (FSWs).

In Hong Kong, the estimated number of sex workers can range from 20,000

to 100,000 in 2001 (Ziteng, 2001). In the recent two decades, the number of sex

workers is likely to rise since there was a dramatic increase in the number of women

crossing the border from mainland China into Hong Kong working as sex workers

(Cheung, 2012; Emerton, Laidler, & Petersen, 2007; Ziteng, 2001).

4
1.1.4. Occupational health and safety of female sex workers

Female sex workers (FSWs) are exposed to multiple occupational health hazards and

are at a disproportionate risk of contracting human immunodeficiency virus (HIV)

infections and other sexually transmitted diseases (STDs) (Ross et al., 2012). In

Hong Kong, although the prevalence of HIV is relatively low among FSWs (Center

for Health Protection, 2014), they are at risk of developing other sexual and

reproductive health problems. The prevalence of urogenital chlamydial trachomatis,

gonorrhea, pharyngeal chlamydia trachomatis, and Neisseria gonorrhea infections

was found to be 10.6%, 0.9%, 3.2%, and 4.4% respectively among female sex

workers in Hong Kong (H. T. Wong, Lee, & Chan, 2015). The prevalence of

abnormal pap smear test results was shown to be 12.46% among FSWs, as compared

to 4.52% among the general population (Leung KM, 2013). The prevalence of

abortion was also high, with approximately 55.6% of FSWs having had an induced

abortion (Lau, Mui, Tsui, Wong, & Ho, 2007).

Beyond sexual and reproductive health problems, FSWs are also vulnerable

to violence, mental health disorders, and substance abuse. A survey conducted by a

non-governmental organization (NGO) in Hong Kong reported that 40.7% of the

FSWs were forced to have unprotected sexual intercourse and 13.3% were

threatened by their clients (Action for Reach Out, 2007). FSWs also experience a

high level of mental disorders (Lau, Tsui, Ho, Wong, & Yang, 2010; Ling, Wong,

Holroyd, & Gray, 2007). It was estimated that among FSWs, 53.9% had symptoms

of depression and 37.7% had suicidal ideation (Lau et al., 2010). Also, there is a

strong link between sex work and illicit drug use, with 40.4% of FSWs using illicit

drugs (Lau et al., 2010). Violence, mental illness, and substance abuse, in turn,

increase the risk that FSWs run of contracting HIV/STD infections (Gu et al., 2010;

5
Shannon & Csete, 2010; Shannon et al., 2008).

1.1.5. Reluctant of sex workers to seek timely treatment

Access to comprehensive and non-discriminatory health care services is imperative

for maintaining and promoting the health and quality of life of FSWs. Despite

universal health coverage, comprehensive services available at public hospitals, and

free sexual and reproductive health care services offered by social hygiene clinics

and numerous NGOs (Kong et al., 2015), many FSWs remain reluctant to seek

timely treatment (Lau, Mui, et al., 2007; Lau et al., 2010; H. T. Wong et al., 2015; W.

C. Wong, Gray, Ling, & Holroyd, 2006). A survey among 89 FSWs in Hong Kong

reported that 55.1% of the participants had never taken STD tests (W. C. Wong et al.,

2006). Another study among 293 FSWs reported that 43.2% of them used illegal

clinics for induced abortion (Lau, Mui, et al., 2007). A more recent survey among

340 FSWs in 2013 has found that the prevalence of HIV and STD screening tests in

the previous year was 44.4% and 45.0%, respectively (H. T. Wong et al., 2015).

Besides, self-medication is not uncommon among FSWs. The prevalence of self-

medication estimated from 494 FSWs who had suspected STD symptoms in the

previous year was 14.1% (Center for Health Protection, 2016).

1.1.6. Stigma is a barrier for sex workers in accessing health care services

Stigma has been recognized as a key barrier that affects the uptake of health care

services by sex workers. Sex workers are stigmatized and marginalized around the

world. They are generally not accepted in society and are regarded as criminals,

immoral troublemakers, sexual deviants, and vectors or reservoirs of disease (Durisin,

Van der Meulen, & Bruckert, 2018; Poutanen, 2015), and have been labeled

―immoral,‖ ―cheap,‖ ―bad,‖ ―greedy,‖ or ―shameless‖ (W. C. Wong, Holroyd, &

6
Bingham, 2011). The criminalization of sex work has deepened the social stigma that

sex workers face (Shannon & Csete, 2010), which contributes to the risk of their

being victimized (Deering et al., 2014).

Health care professionals, as members of society, are also influenced by the

general public‘s attitude towards sex workers. Accordingly, stigma and

discrimination towards sex workers persist within health care facilities. The poor

attitudes of healthcare providers, their humiliating treatment, the receipt of unequal

treatment, longer waiting times, breaches of confidentiality, mandatory testing for

HIV, and even sexual harassment (Basnyat, 2017; Chakrapani, Newman,

Shunmugam, Kurian, & Dubrow, 2009; Lafort et al., 2016; Phrasisombath, Thomsen,

Hagberg, Sychareun, & Faxelid, 2012) have deterred sex workers from seeking

health care and led to unmet health needs.

Timely and quality health care could be considered as a basic human right.

The Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health

Organization (WHO), and sex workers‘ advocacy groups have emphasized the

importance of showing respect for the human rights of sex workers and promoting

zero discrimination in healthcare settings (The Joint United Nations Programme on

HIV/AIDS, 2017). The World Health Organization (WHO) has recommended that all

health services, including primary health care, should be made ―available, accessible

and acceptable to sex workers based on the principles of avoidance of stigma, non-

discrimination and the right to health‖ (p. 8) (World Health Organization, 2012).

Therefore, sensitivity training and programmes to reduce stigma toward sex workers

among health care professionals should be carried out.

1.1.7. Preparing nurses to care for sex workers

As the largest group of frontline healthcare providers, nurses are usually the first

7
point of contact for clients and have more interactions with patients than other health

professionals. Caring is the essence of nursing practice (Lemonidou,

Papathanassoglou, Giannakopoulou, Patiraki, & Papadatou, 2004). As health

professionals, nurses should be prepared to provide care to the diverse health care

needs of the community, including providing non-judgmental holistic care for all,

including marginalized populations. Preparing nurses and nursing students with

cultural competencies is of great importance since this will affect their social

awareness, accountability, responsibility, and the care that they will provide in their

practice, which inevitably influences the health status and access to health care of

sex workers.

Although recognition of the impact of stigma on the access of health care by

sex workers has grown, there has been no study focusing on the experiences of sex

workers with accessing health care services in Hong Kong. Although the association

between the attitude of stigma held by health care providers and the utilization of

health care services by sex workers has been established, little research has been

conducted on the attitudes and willingness of nurses and nursing students to provide

care for sex workers in Hong Kong.

In Hong Kong, commercial sex is not considered illegal, but subject to

various restrictions, activities such as soliciting for immoral purposes are prohibited

(Hong Kong Crimes Ordinance (Cap 200), 1990). Among the Hong Kong population,

there is still a general stigma towards sex workers. Nurses, as members of the

general public, may hold similar perceptions of this disadvantaged population. Up to

now, there is not much understanding of the impact of the stigma of sex work on the

access and quality of healthcare services for sex workers in Hong Kong. Also, it is

not common in most nursing education programmes to teach students how to care for

8
these clients. Little is known about whether nursing students and nurses are prepared

to care for sex workers upon graduation. A better understanding of the views from

both sex workers and nurses will provide the direction and suggestions for the

development of stigma reduction interventions for nurses or nursing students.

1.2. Research aims and objectives

This study aims to examine the stigma of sex work and associated health care

services from the perspectives of sex workers, nurses, and nursing students in Hong

Kong, and to develop an intervention to reduce stigma towards sex workers among

nurses.

The objectives of this study are: (1) explore how sex workers experience

stigma and develop coping strategies when accessing health care services in Hong

Kong; (2) to explore the knowledge, attitudes, and willingness, of Hong Kong nurses

in relation to the issue of providing care for sex workers; (3) to examine and

compare students in the general and mental health nursing programmes in Hong

Kong in terms of their knowledge of, attitudes towards, and willingness to care for

sex workers in their future practice; (4) to develop a conceptual framework to

understand the stigma toward sex workers among nurses; (5) to develop an

intervention to reduce stigma towards sex workers among nurses in Hong Kong.

1.3. Project significance and value

It will be the first study in Hong Kong that focuses on understanding the stigma of

nurses and nursing students toward sex workers, in establishing the evidence needed

to develop an intervention to reduce stigma towards sex workers among nurses in

Hong Kong. The study will contribute to a better understanding of the health and the

barriers to accessing health care services of sex workers in Hong Kong. It will also

9
help to raise the nurses‘ and nursing students‘ awareness of their attitudes and

disparities in health and health care access among sex workers. Findings of this study

can be especially of interest for empathy education, equality in health and access to

health care services, and the development of stigma reduction interventions for

nursing students in the future.

1.4. The adopted Medical Research Council (MRC) framework

The Medical Research Council (MRC) framework was adopted to guide the

development, evaluation, and implementation of complex interventions in the health

services (Craig et al., 2008; Medical Research Council, 2019). A complex

intervention refers to an intervention that contains several interacting components or

difficulty of behaviours required by those delivering or receiving the intervention

(Craig et al., 2008).

1.4.1. The developing, evaluating, and implementing process of a complex

intervention

As shown in Figure 1-1, the MRC framework involved four stages, including

development, feasibility/piloting, evaluation, and implementation (Medical Research

Council, 2019).

10
 Feasibility/piloting
1 Testing procedures
2 Estimating recruitment/retention
3 Determining sample size

Development Evaluation
1 Identifying the evidence base 1 Assessing effectiveness
2 Identifying/developing theory 2 Understanding change process
3 Modelling process and outcomes 3 Assessing cost-effectiveness

Implementation
1 Dissemination
2 Surveillance and monitoring
3 Long term follow-up

Figure 1-1. Key elements of the development and evaluation process

(Medical research council, 2019)

The stage of developing a complex intervention involved three steps: the first step is

to identify the relevant, existing evidence through conducting systematic reviews, to

establish evidence needed for a specific population. Then, identifying and

developing an appropriate theory holds more potential for the development of an

effective intervention than purely depend on an empirical or pragmatic approach.

Lastly, modelling a complex intervention prior to a full-scale evaluation may provide

important guidance on the development and evaluation of the intervention.

The stage of feasibility and piloting involves testing procedures, estimating

the recruitment or retention of the participants, and determining the sample size.

In the stage of evaluation, the types of study designs should be decided based

on the research question and circumstances. Awareness of the whole range of

experimental and non-experimental approaches may enable researchers to make

more appropriate methodological choices.

Regarding the implementation, a few methods were suggested, such as

11
publication in the research literature, or integrating the findings into routine practice

or health policy.

1.4.2. Studies conducted in developing an intervention to reduce stigma towards

sex workers among nurses in Hong Kong

Following the MRC framework of developing-evaluating-implementing a complex

intervention, this thesis covers the first stage: Development. Figure 1-2 shows the

key elements in the first phase of developing an intervention. This phase involves

three steps: (1) identifying evidence by conducting relevant reviews (Chapter 2-4,

6), reviewing the definitions and conceptualizations of stigma (Chapter 5),

conducting a qualitative study on the perspectives of practicing nurses toward caring

for sex workers in Hong Kong (Study I), conducting a qualitative study on the

experience of female sex workers with accessing health care services in Hong Kong

(Study II), and carrying out a cross-sectional study on the knowledge of, attitudes

towards, and willingness to care for sex workers among the undergraduate nursing

students (Study III); (2) identifying and developing a theory – a preliminary

conceptual framework to understand the stigma toward sex workers among nursing

students; (3) developing and presenting the related contents of the programme to

reduce stigma towards sex workers among nurses.

1.5. Outline of the thesis

This thesis is presented in three parts and 14 chapters in accordance with the research

process, from the introduction of study (Part I), the review of the literature (Part II),

the study conducted (Part III), to conclusions and implications for practice and future

research (Part IV).

12
 Part I includes the research background and significance of exploring the

stigma of sex work and associated health care services from the perspectives of sex

workers, nurses, and nursing students. It also highlights the significance of

developing an intervention to reduce stigma towards sex workers among nurses in

Hong Kong (Chapter 1).

Part II included four literature reviews (Chapter 2-4, 6). For a better

understanding of the stigma associated with sex work, a series of reviews were

conducted. Chapter 2-4 and Chapter 6 provided an overview of the studies related to

the stigma of sex work. The reviews of the literature included: sex workers and

motherhood (Chapter 2); attitudes of different stakeholders towards sex workers

(Chapter 3); barriers and facilitators to the accessing of health services by sex

workers (Chapter 4); HIV/AIDS-related stigma-reduction intervention for

professionals and students in health-related disciplines – implications for stigma-

reduction interventions related to sex work (Chapter 6). Chapter 5 described the

conceptualization of the stigma and the impact of stigma on sex workers. Chapter 7

provides a summary of the reviews of the literature and the rationale for the choice

of the methodology of the study.

Part III presents the studies according to the MRC framework (Chapter 8-

13). It consists of three stages. In stage one, a series of studies were conducted to

identify the stigma of sex work and associated health care services from the

perspectives of sex workers, nurses, and nursing students in the local context

(Chapter 9-11). Study I explored the perspectives of practicing nurses toward caring

for sex workers (Chapter 9). Study II investigated the experience of FSWs with

accessing health care services (Chapter 10). Study III examined and compared

13
students in the general and mental health nursing programmes in Hong Kong in

terms of their knowledge of, attitudes towards, and willingness to care for sex

workers in their future practice (Chapter 11).

In stage two, a preliminary conceptual framework was developed to

understand the stigma toward sex workers among nurses in Hong Kong (Chapter

12).

In stage three, an intervention to reduce stigma towards sex workers among

nurses was developed by using the preliminary conceptual framework (Chapter 13).

Finally, Part IV is the conclusion of the study and the implications for

nursing education and future research. The limitations of the study and the

recommendation for future researches were presented (Chapter 14).

14
 Process of MRC framework Studies conducted

 Literature review: Conducting a series of an extensive

review of studies related to the stigma of sex work
Step 1
(Chapter 2-4, 6), review the definitions and
Identifying the
conceptualizations of stigma (Chapter 5)
evidence base
 Study I: Conducting a qualitative study on the
perspectives of practicing nurses toward caring for sex
workers in Hong Kong (Chapter 9)
 Study II: Conducting a qualitative study on the
experience of female sex workers with accessing health
care services in Hong Kong (Chapter 10)
 Study III: Conducting a cross-sectional study on the
Phase 1 knowledge of, attitudes towards, and willingness to care
Developing the for sex workers among the undergraduate nursing
complex intervention students (Chapter 11)

Step 2 Proposing a preliminary conceptual framework to

Identifying / understand the stigma toward sex workers among nurses
developing theory (Chapter 12)

Step 3 Developing and presenting the related contents of the reduce

Modelling process stigma towards sex workers among nurses programme
and outcomes (Chapter 13)

Figure 1-2 Process of MRC framework and studies conducted corresponding to

MRC framework in developing the intervention

15
 PART II IDENTIFYIGN THE EVIDENCE BASED IN THE

PROCESS OF MRC FRAMEWORK: REVIEWS OF LITERATURE

16
 Chapter 2 Review of literature (I)

Sex workers and motherhood

[Link] experience in working with sex workers and initial intention for my PhD

study

Conflicting identities between sex workers and motherhood: A systematic

review

[Link] of the review

[Link]

2.3.1. Search strategies and study selection process

2.3.2. Inclusion and exclusion criteria

2.3.3. Assessing the quality of the methodology

2.3.4. Data Synthesis

[Link]

2.4.1. Characteristics of the selected studies

2.4.2. Assessing the quality of the included studies

2.4.3. Findings from qualitative studies

2.4.4. Differences in findings across countries

2.4.5. Findings from quantitative studies

[Link]

[Link]

[Link]

[Link] for future research

*Content of this chapter is published (partial content included in this chapter):

Ma, P. H., Chan, Z. C., & Loke, A. Y. (2019). Conflicting identities between sex

workers and motherhood: A systematic review. Women & health, 59(5), 534-557.

17
2.1. My experience in working with sex workers and initial intention for my

Ph.D. study

Almost ten years ago (2009), I worked as a research assistant and a nurse in a clinic

at one of the non-governmental organizations (NGOs) that serve sex workers. The

work experience provided me a valuable opportunity to hear the life stories of female

sex workers (FSWs) who visited the clinic. The FSWs frequently talked about their

family and children, and many confessed that they engaged in sex work in order to

raise their children.

Among these women, the stories of two migrant sex workers from mainland

China touched me. One woman was diagnosed with cervical cancer but was reluctant

to return to her hometown in China for timely treatment. She murmured: ―I have not

earned enough money for my son‘s school fee, which is more important to me.‖

Another single mother, who was a successful businesswoman but went bankrupt due

to gambling. She did not want her daughter to worry about their economic status, so

she decided to engage in sex work to continue to provide her daughter with the same

level of lifestyle they had before. She laughed bitterly, ―My daughter thought I come

to Hong Kong for business. Little does she knows that her mother is selling her

body!‖

Many of them told me that they never thought of revealing their work to the

family. Some commented, ―Of course, we wouldn‘t dare to tell anyone. Nobody

would want to tell others they are ‗chicken‖ (a Chinese term used to refer to

prostitute in Hong Kong). It is not a decent job. They further commented that if their

villagers or neighbours knew about their work, they would look down on us and

curse us, and say something like it is considered as retribution for ancestors‘ evil

deeds. They tried very hard and every means to hide their identity as a sex worker

18
and lived a life with different identifies in front of others.

As a mother of two young children, I felt deeply that being a mother is one of

the most challenging jobs in the world. I could imagine how tough it is to be a single

mother having to raise a child(ren), by engaging in sex work. It must take a lot of

courage, lots of fear, or feeling ‗dirty‘ of themselves, and perhaps self-stigma. In

hearing the stories of these ‗brave‘ mothers, I started to wonder how sex workers

cope with conflicting identities as a mother as a sex worker. I was hoping that I could

do something to help them, so I started my review of the literature on the conflicting

identities of sex workers and motherhood.

The first step I took was to identify and to synthesize the existing literature

that focused on the challenges of FSWs in negotiating their maternal identity with

their stigmatized identity as sex workers.

19
Conflicting identities between sex workers and motherhood: A systematic

review

2.2. Background of the review

Being a mother is regarded as a traditional and central role of a woman. It is often

considered the source of a woman‘s self-esteem, pride, and sense of fulfillment. It

can have a great impact on how women see themselves in a wider social context

(Burden et al., 2016). Motherhood is not merely about having children but also about

being a good mother. Although various definitions of motherhood have been

suggested (Couvrette, Brochu, & Plourde, 2016; Malacrida, 2009), predominate

concepts of ―good mothers‖ refer to those who are selfless and place the needs of

their children over their own (Malacrida, 2009). Those who fail to meet these social

expectations are frequently castigated as bad or inadequate mothers (Couvrette et al.,

2016). However, sex workers should be regarded as individuals enjoy human rights,

and social expectations of mothers sometimes may lack of awareness of individual

needs of working mothers.

Sex worker possesses various identities. Many female sex workers (FSWs)

are also mothers with at least one child (W. C. W. Wong, Yim, Leung, Lynn, & Ling,

2012). However, the effect of criminalization, stigma, and other forms of

discrimination could extend into their family lives and impair their capacities as

mothers. In extreme circumstances, FSWs may be susceptible to arbitrary moral

judgments of them as unfit mothers and experience termination of their parental

rights (Dziuban, 2015). The story of a Swedish sex worker named Petite Jasmine is a

particular tragedy. Because of her occupation, she was deemed an unsuitable parent

by the court and was killed by a violent ex-partner who had been granted full

custody of her children (Dziuban, 2015). However, social justice and positive

20
impacts of all occupations should be advocated, including those of FSWs.

Given the fact that the stigmatized identity of sex workers may have a

significant impact on their identities, their motherhood, and subsequently their health

and their children‘s well-being, a better understanding of their maternal difficulties

and concerns would help to address the gaps in supportive services for FSWs. The

aim of this review was to synthesize the results of studies focusing on the challenges

that FSWs faced in negotiating their dual identities as sex workers and mothers, and

provide direction for the development of services and interventions for this

disadvantaged female population and their children.

2.3. Methods

2.3.1. Search strategies and study selection process

Seven electronic databases, including MEDLINE, PubMed, PsycInfo, CINAHL, the

British Nursing Index, Web of Science, and ProQuest Dissertations & Theses were

searched for studies published to prior to March 2016 that explored the experiences

and challenges faced by FSWs as mothers. Search terms included medical subject

headings (MeSH) terms and text words for ―sex worker‖ and terms associated with

―mother‖: (1) sex worker (―sex worker‖ OR ―prostitution‖); (2) mother (―mother*‖

OR ―parent*‖ OR ―maternal‖); and (3) experience (―experience‖ or ―stigma‖ or

―difficult*‖ or ―challenge‖ or ―concern‖ or ―social expectation‖ or ―identity‖ or

―role‖). No other restrictions were placed on years of publication. A manual search

for additional literature was made from the reference lists of all of the retrieved

articles and existing review articles.

21
2.3.2. Inclusion and exclusion criteria

The criteria for studies to be included in this review were original articles published

in English that examined the motherhood experience of FSWs. Studies whose focus

was the reasons for entering into the sex trade or on the life experiences of FSWs,

other than the experience of motherhood, or review articles, were excluded.

2.3.3. Assessing the quality of the methodology

The Mixed Methods Appraisal Tool (MMAT-Version 2011) developed by Pluye et

al. was used to assess the quality of the included studies (Pluye et al., 2011). It

proposes evaluation criteria for qualitative, quantitative, and mixed methods studies.

MMAT contains four criteria for qualitative and quantitative studies. All of the

qualitative and quantitative component criteria are used for mixed methods studies.

Criteria for appraising studies are checklist questions with possible answers of ―Yes‖,

―No‖, or ―Can‘t tell‖. For qualitative and quantitative studies, scores range from 0%

when no criterion is met to 100% when all four criteria are met. Each paper was

assigned a grade of 0% (no quality), 25% (low quality), 50% (moderate quality),

75% (considerable quality) and 100% (high quality). For mixed-method studies, the

overall quality is determined by the component with the lowest quality.

2.3.4. Data Synthesis

Textual narrative and a thematic synthesis approach were adopted to synthesize the

key themes that were identified in the included studies. In stage one, a textual

narrative synthesis of the characteristics, key findings, and conclusions of individual

studies were tabulated.

In stage two, a thematic synthesis approach was adopted to synthesize the

22
key themes that were identified in the included qualitative studies (Thomas &

Harden, 2008): (1) line-by-line coding of the findings of the primary studies; (2)

development of descriptive themes; (3) and generation of analytical themes. Data for

thematic analysis were only extracted from the ―results‖ or ―findings‖ section of

included studies, with particular attention to the quotations from FSWs and the

authors‘ interpretations in the report related to FSWs experience of dual identities.

The excerpts in findings were coded, supported by the descriptive and preliminary

analytical themes and subthemes. For mixed-method study used predominately

qualitative methods for data collection and data analysis, it was allocated to the pool

of qualitative studies.

For the quantitative studies, formal statistical analysis was not feasible

because of the heterogeneity of the measurements. The findings that relevant to the

aims of the review were extracted. For mix-method study used predominately

quantitative method for data collection and analysis, it was allowed to the pool of

quantitative studies.

2.4. Results

A total of 1,233 abstracts were retrieved from the electronic databases and eight

additional records were identified through a manual search. After 210 duplicate

publications were eliminated, 1,031 abstracts were screened. A total of 1002

publications were excluded based on the exclusion criteria. Of these, 18 were review

articles, 961 articles were not related to the research topics, and 23 articles were

published in languages other than English. The full texts of the remaining 29 articles

were examined in detail, and eight additional studies were excluded with reasons.

23
Finally, a total of 21 studies were considered eligible and were included in this

review (Figure 2-1).

Records identified through Additional records identified

database searching through hand search (n = 8)
Identification

(n = 1233)

Records excluded
(n = 1002)
1. Review articles (n=18)
2. Studies not related to
Records after duplicates removed female sex workers
(n = 1031) (n=865)
3. Studies not related to
motherhood (n=96)
Screening

4. Other languages (n=23)

Records screened
(n = 1031)

Full-text articles excluded, with

reasons (n = 8)
Full-text articles assessed for 1. Full-text PhD thesis was not
Eligibility

eligibility accessible (n = 1)
(n = 29) 2. Studies on the reason of entry/
reproductive health/social work
group/gernal health of sex worker
and their children (n = 4)
3. Comparison of offenders
(n = 1)
4. Duplicate publication (n=2)
Included

Studies included in Studies included in Studies included in

qualitative synthesis quantitative synthesis combined qualitative and
(n = 13) (n = 5) quantitative synthesis
(n = 3)

Figure 2-1 The flow diagram on identifying the literature

24
2.4.1. Characteristics of the selected studies

The sample size ranged from five to 136 for the included 13 qualitative studies, from

87 to 850 for five quantitative studies, and from 60 to 428 for three mixed-method

studies (Appendices Table 2-1). Two mixed-method studies were classified as mixed

but predominately qualitative studies (Pardeshi & Bhattacharya, 2006; Rolon et al.,

2013), and one was classified as mixed but predominately quantitative study (Chege,

Kabiru, & Mbithi, 2002). Seven studies had been conducted in Asia, two studies in

Europe, seven studies in North America, four studies in Africa, and one

multinational study had been carried out in both the U.S. and India.

The law on the prostitution of the included studies is complicated, and the

level of enforcement varies by country. In general, all countries criminalize some

aspects of sex work (Appendices Table 2-2).

2.4.2. Assessing the quality of the included studies

Quality appraisal of all the included studies showed that: two studies met one

criterion and rated 25%; 14 studies met two criteria and rated 50%; four studies met

three criteria and rated 75%; and only one study met all of the criteria and rated

100% (Appendices Table 2-3). Most studies did not report the reasons why potential

respondents refused to participate (n=17); the majority of studies provided no

consideration of researchers‘ influence during data collection (n=14); and one-third

of studies did not provide the response rate (n=7). None of the published papers was

excluded from this review because of quality.

Regardless of the legal status of prostitution in the countries included in this

review, the struggles of FSWs in managing their dual identities were mostly similar.

25
2.4.3. Findings from qualitative studies

Common themes that emerged from the data across countries

Two themes that emerged as central to the dual identities of FSWs were:

“Conflicting identities between the jobs as sex workers and motherhood‖, and

―Responses to social expectations of ideal motherhood‖ (Appendices Table 2-1).

Theme 1. Conflicting identities between the jobs as sex workers and motherhood

Being a mother while having to negotiate the problems of poverty, the absence of a

supportive partner, sex work, addiction, incarceration, social stigma, and adverse

situations can be challenging. FSWs were likely to experience motherhood in

overwhelmingly negative ways.

Exposing children to an unsafe environment – Occupational hazards and

marginalized lifestyles had some adverse effects on the parenting practices and

capabilities of some FSWs. Multiple risks, such as sexually transmitted infections

(STIs), addiction, violence, malnutrition, and inadequate prenatal care, could

increase their chances of experiencing a miscarriage, stillbirth, or congenital birth

defects in their children, and could increase their children‘s vulnerability and

exposure to violence, sex abuse, sexual activity, drug addiction, and engagement in

the sex industry (Bletzer, 2005; Chege et al., 2002; Dalla, 2004; John-Fisk, 2013;

McClelland & Newell, 2008; Pardeshi & Bhattacharya, 2006; Sloss & Harper, 2004;

Willis, Hodgson, & Lovich, 2014; Yerpude & Jogdand, 2012; Zalwango et al., 2010).

Stigma and laws that undermine FSWs’ abilities to be mothers – In some

circumstances, stigma and laws compromised FSWs‘ capabilities to be mothers and

26
to seek equal education, health services, and other social services for their children.

For example, without a valid marriage certificate or proof of residential address or

merely because of sex work, FSWs would not be eligible in some countries to apply

for rental public housing or get school admissions for their children (Goh &

Praimkumara, 2015; John-Fisk, 2013; Willis et al., 2014; Yerpude & Jogdand, 2012).

FSWs also received little protection from law enforcement authorities. FSWs from

Bangladesh reported that even when their children were abducted, police officers

rarely helped to search for them (Willis et al., 2014).

Internalizing stigma – FSWs were aware of the stigma attached to sex work and the

consequences for their children. They internalized the stigma and tended to see their

dual identities as conflicting, which had the effect of diminishing their self-esteem

and increasing their mental health problems (Beckham, Shembilu, Winch, Beyrer, &

Kerrigan, 2015; Bletzer, 2005; Chege et al., 2002; Dalla, 2004; Duff et al., 2014;

Goh & Praimkumara, 2015; John-Fisk, 2013; Peled & Parker, 2013; Sloss & Harper,

2004; Zalwango et al., 2010). Those who had lost their parental rights felt particular

grief and stated that their future seemed hopeless, and some FSWs took drugs or

increased their sex work to numb the sadness (Bletzer, 2005; Dodsworth, 2014;

John-Fisk, 2013; McClelland & Newell, 2008; Rolon et al., 2013; Sloss & Harper,

2004).

Theme 2. Responses to social expectations of ideal motherhood

Motherhood provided valuable meaning to the lives of the FSWs and was a source of

self-esteem and strength. They idealized motherhood and attempted to adopt various

strategies to respond to social expectations regarding good motherhood.

27
Justification of sex work – In most circumstances, sex work was seen as the only way

to give the children of FSWs monetary support. FSWs resisted the implicit social

label of ―unfit mother‖ by emphasizing that they were capable of meeting their

children‘s needs and keeping their children away from harm, and considered their

separation from or relinquishment of their children as a form of ―good mothering‖

(Bletzer, 2005; Dalla, 2004; Dodsworth, 2014; John-Fisk, 2013; Rivers-Moore, 2010;

Zalwango et al., 2010).

Restore positive social identity – Motherhood also brought changes to the lives of the

FSWs. Many FSWs were motivated to be a good role model for their children and

made attempts to leave the sex industry and get clean of drugs (Bletzer, 2005; Dalla,

2004; Dodsworth, 2014; Goh & Praimkumara, 2015; John-Fisk, 2013; Rolon et al.,

2013; Sloss & Harper, 2004). Some of them reported that they had found other work,

completed a drug treatment program, and started a new life with their children (Dalla,

2004; Goh & Praimkumara, 2015; Rolon et al., 2013).

Social support networks – Networks of social support played a critical role in

upholding the capacity of FSWs to function as mothers. For example, non-

governmental organizations (NGOs) in India and Singapore provided FSWs with

resources and training, such as food, clothing, safe shelter, residential schools for

their children, reached out to the children of FSWs, and skills training (A. Basu &

Dutta, 2011; Goh & Praimkumara, 2015; Yerpude & Jogdand, 2012). Such external

social support significantly relieved the FSWs of the stress and burden of caring for

their children, and created opportunities for them to protect and maintain their

identity as mothers.

28
2.4.4. Differences in findings across countries

Child custody – FSWs may relinquish care over their child to the child‘s father,

extended family, friends, or to social services. Child fostering for children of FSWs

was a frequent practice throughout sub-Saharan Africa, and it was adopted by FSWs

in Uganda as means to distance their children from their work (Zalwango et al.,

2010). FSWs from developed countries, such as the U.S., United Kingdom, Canada,

Mexico, and Singapore, were more likely to report having been forced to relinquish

their children due to their sex work, drug use, violence, homeless, incarceration, and

other marginalized lifestyles (Bletzer, 2005; Dalla, 2004; Dodsworth, 2014; Duff et

al., 2014; Goh & Praimkumara, 2015; John-Fisk, 2013; McClelland & Newell, 2008;

Rolon et al., 2013; Sloss & Harper, 2004). However, among FSWs who raised their

children in the red light area in India, none of them reported losing custody of their

children (John-Fisk, 2013).

2.4.5. Findings from quantitative studies

Findings from quantitative studies shared a common observation that motherhood

has a great impact on FSWs‘ choice of sex work, work practice and access to health

care and social services (Duff et al., 2015; Papworth et al., 2015; Reed et al., 2013).

Some FSWs might prioritize their child-rearing obligations over their health. A study

conducted in India showed that FSWs who had three or more children or child with

health concerns were less likely to report consistent condom use (adjusted odds ratio

(AOR) range: 0.5-0.6), and more likely to make more money for sex without

condom (AOR: 2.5, 95% confidence interval (CI): 1.6-3.9) (Reed et al., 2013).

While some FSWs preferred to stay healthy for their children and were cautious of

HIV-related risk behaviors. In Burkina Faso, motherhood was a predictor of having

29
reduced unprotected vaginal or anal sex with new clients (age-adjusted odds ratio

(aaOR): 0.80, 95% CI: 0.65-0.97), and a predictor of limited difficulty when

accessing health services (aaOR, 0.15, 95% CI: 0.67-0.34) (Papworth et al., 2015).

In a similar vein, results from the quantitative studies also described the

challenges in FSWs double lives. In Canada, the prevalence of losing child custody

among FSWs was 38.3%, and around 30% of them required counseling to deal with

the trauma associated with losing child custody (Duff et al., 2014). Nearly 13% of

FSWs avoided seeking social services for the fear of losing custody of their children

(Duff et al., 2015). Although FSWs in some developing countries had their child

custody, there was a possibility that they might expose their children to risks. For

example, in India, around 34.69% of the children of FSWs were raised in the brothel

(Yerpude & Jogdand, 2012). In Kenya, 75.1% of FSWs practiced prostitution at

home (Chege et al., 2002). Besides, FSWs faced difficulties in getting school

admissions for their children in India (Yerpude & Jogdand, 2012), and around 41%

of children of FSWs in Kenya had to drop out of school due to poverty (Chege et al.,

2002).

2.5. Discussion

This review showed homogeneity across various countries, in that motherhood was

an important identity for FSWs and influenced their lives, self-esteem, and decisions.

Their life stories tell us that some FSWs were good mothers, sacrificing their dignity

and safety and engaging in stigmatized sex work, while proving that they were

devoted mothers by giving priority to their children‘s needs above their own. The

complexity of the challenges facing FSWs in negotiating their dual identities as a sex

worker and mother need to be addressed. Relevant services and interventions that

30
potentially change the lives of FSWs and their children are discussed below.

Although FSWs have received increasing attention from researchers and

policy-makers, existing research has primarily focused on their occupational risks,

such as HIV, stigma, and violence. FSWs dual identities as a sex worker and mother

received little attention in both the academic and policy literature. One possible

explanation is that sex workers are defined by their job, which may lead the

difficulty in recognizing the multiple roles of FSWs (Sleightholme & Sinha, 1996).

However, sex work and motherhood are intertwined, and thus were precisely the

areas that needed to be studied; the full range of sexual and reproductive health

needs of FSWs should be met. Traditional HIV programs may require to expand their

services alongside broader reproductive health services and parenting training.

Comprehensive reproductive health services recommended by the Joint United

Nations Programme on HIV/AIDS (UNAIDS) may include family planning

counseling, contraception and reproductive health service, pregnancy and antenatal

services, unintended pregnancy, abortion and post-abortion care, parenting

mentoring, parenting skills training, and pediatric care (World Health Organization,

2013).

The multiple identities of FSWs inform us that FSWs are real people who

have families and multiple roles. They should be entitled to the same equal rights to

health and safety as anyone else. Programs for FSWs may need to address the

challenges within various contexts of FSWs‘ lives. They should take a holistic

approach to support FSWs, such as housing, addiction, mental health services,

economic support, legal advice, child-care, and access to health, social and financial

services. Meanwhile, programs and services should be sensitive to the stigma

associated with sex work. Service providers, including health care providers,

31
counselors, and social workers, should be provided with training to work with FSWs

and offer non-judgmental services.

Sex work itself does not affect competence in the maternal role. However,

stigma, criminalization, and other marginalizing factors constrained FSWs‘ maternal

capacity and challenged their and their children‘s health, safety, well-being and

human rights. A critical approach in dealing with conflicting dual identities is policy

change. Researchers, feminists, and social activists are calling for the full

decriminalization of prostitution (Decker et al., 2015). Experience may be drawn

from New Zealand‘s model of decriminalization, which could empower sex workers

and increase their safety, rebalance power relationship between police and sex

workers, improve sex workers‘ access to health and social services without fear of

being penalized, resulting in greater willingness to report incidents of violence to

police (Armstrong, 2017). This approach may also hold the potential to improve the

lives of FSWs and their children, as well as increase public awareness about respect

for this group of women.

2.6. Limitations

This review had two potential limitations. First, the quality of the studies that were

included varied, and a decision was made not to exclude two studies that only met

one MMAT criteria. The two studies investigated childrearing practices in brothels

and provided rich information to assist in understanding the vulnerability faced by

the children of FSWs (Chege et al., 2002; Pardeshi & Bhattacharya, 2006). Thus, the

decision was made to include them in this review. Second, this review only included

published articles, while the grey literature relating to this topic was not explored.

Thus, this review may be susceptible to publication bias.

32
2.7. Summary

Motherhood is central to the lives of many FSWs. However, motherhood poses an

additional challenge for this vulnerable and disadvantaged population. An

understanding of FSWs‘ world is vital to address their and their children‘s health and

safety needs. A more holistic approach is necessary to meet FSWs‘ health, economic,

and social needs, such as sexual and reproductive health service, addiction treatment,

mental health services, financial support, and legal advice. Services should be

provided in a sensitive and non-judgmental manner. Further, to advance the health

and safety of FSWs and their children, prostitution law may need to move toward

decriminalization of sex work. This review will contribute to raise the awareness of

the general public toward FSWs as an individual and mother. Social inclusion will be

the dream for all women.

2.8. Recommendations for future research

This systematic review provided several insights for future studies. First, key

stakeholders, such as the general public, health care professionals, social workers,

and legal authorities, may play a significant role in the lives of FSWs, their

perceptions of FSWs deserve further exploration. Secondly, to expand our

knowledge of the effects of the legal environment and culture on FSWs and their

children‘s lives and child custody arrangements, it would be valuable to explore the

experiences of FSWs in countries where prostitution is fully decriminalized or less

stigmatized.

This review also provided a better understanding of sex workers as persons

with families and multiple roles, who are also entitled to equal human rights to

health and social services. After completing this review, I learned that I do not have

33
the personal and professional capacity to offer these sex workers the necessaries and

social resources as mothers. Instead, I felt that as a nurse, I should focus on the ways

to improve their health or health behaviours, and access to health services. I also

learned from the review that various stakeholders could shape the day-to-day life of

sex workers and impact on their physical and mental health, I then decided to

embark on a review to explore the attitudes of various stakeholders toward sex

workers, and the impacts on the health of sex workers.

34
 Chapter 3 Review of literature (II)

Attitudes of Different Stakeholders towards sex workers

[Link]

[Link] of this review

[Link]

3.3.1 Search strategies and study selection process

3.3.2 Inclusion and exclusion criteria

3.3.3 Assessing the quality of the included literature

3.3.4 Data extraction

[Link]

3.4.1. Characteristics of the selected studies

3.4.2. Quality of the included literature

3.4.3. Attitudes toward sex workers

3.4.4. Attitudes toward prostitution laws

[Link]

[Link]

[Link]

3.8. Recommendation for future research

*Content of this chapter is published (partial content included in this chapter):

Ma, P. H., Chan, Z. C., & Loke, A. Y. (2018). A Systematic Review of the Attitudes

of Different Stakeholders towards Prostitution and Their Implications. Sexuality

Research and Social Policy, 15(3), 231-241.

35
3.1. Background of the review

Sex workers‘ legal status is closely associated with their working conditions and

health outcomes (Deering et al., 2014). Since the 1980s, there has been an increasing

debate regarding the three legislative approaches to the policing and regulation of

prostitution internationally: criminalization, legalization, and decriminalization

(Barnett, Casavant, & Nicol, 2011).

Under the criminalization laws, sex work is viewed as an immoral profession

and criminal offense. Activities associated with prostitution, such as purchasing sex,

selling sex, running brothels, living on the earnings of the prostitution, are all

criminalized. Numerous evidence shows that the criminalization approach violates

sex workers‘ human rights, undermines their abilities to protect themselves, and

limits access to services (Lea, Callaghan, Grafton, Falcone, & Shaw, 2016; Qiao et

al., 2014).

Contrary to the criminalization of prostitution, the legalization of prostitution

views prostitution as a legal profession and regulates it through criminal law, labour

law or other legislation, such as registering or mandating health checkups. It aims to

eliminate criminal involvement in the prostitution industry and protect prostitutes

from commercial exploitation and safeguard the health and safety of sex workers

(Barnett et al., 2011). However, evidence suggests that this approach leads to a mass

increase in sex trafficking from illegal countries to legal countries, increases the

underground sex industry and further victimizations and exploitation of sex workers.

On January 1st, 1999, Sweden adopted an alternative legal route, which is known as

the ―Nordic model‖, in which only the buyers of sex are prosecuted (SFS, 1998). The

number of street sex worker appears declined, while other forms of solicitation

methods such as mobiles phones and the internet have increased (Chu & Glass,

36
2013). This approach has also been criticized for pushing sex workers into more

hidden locations and reinforcing violence against them.

The third approach is the decriminalization of prostitution. It means the

removal of laws against prostitution and relies on the use of existing statutes and

regulation to manage the operation of the sex industry (Barnett et al., 2011). In 2003,

New Zealand passed the Prostitution Reform Act (PRA) 2003 and became the first

country to decriminalize sex work in the world (Mossman, 2005). This approach is

considered as a more successful method to safeguard human rights and contribute to

the betterment of the lives of sex workers. It is reported that sex workers felt

empowered and more willing to report crimes to police. Global health and human

rights organizations are calling for the decriminalization of prostitution and the

elimination of the unjust application of non-criminal laws and regulations against sex

workers (Amnesty International, 2015; Decker et al., 2015).

However, among various viewpoints toward prostitution laws, radical

feminists and liberal feminists contrast sharply on the issue of the legal status of

prostitution (Limoncelli, 2009). Radical feminists view prostitution as the

exploitation and oppression of women. They believe that decriminalizing sex work

will not protect women engaged in prostitution, but will only promote sex trafficking

and violence against women. In contrast to radical feminists, liberal feminists regard

prostitution as an occupational choice, and argue that a woman is free to enter into

the sex industry. They blame the criminalization of prostitution for violating

women‘s rights and call for empowering prostitutes through decriminalization. Thus

far, while policy-makers, feminist academics, and activists have discussed the ideal

legal framework for prostitution, they have been unable to reach a

consensus(Schulze, Canto, Mason, & Skalin, 2014).

37
 As Eiser (1994) argues that ―our attitudes make, or at least predispose, us to

act the way we do‖ (p.19) (Eiser, 1994). Studying different stakeholders‘ attitudes

toward sex workers and prostitution law is important because such attitudes could

reveal how individual‘s interaction with sex workers and affect their lives (Basnyat,

2017; Wojcicki & Malala, 2001). Also, it is important to understand and compare

different stakeholders‘ attitudes toward a morally ambiguous issue because it has

clear policy relevance. Policy-makers, especially in a democratic society, usually

take into consideration the opinions and interests of stakeholders into account during

the policy-making process (Baldassarri & Gelman, 2008; Brooks & Manza, 2006).

Under the context of human rights violate among sex workers in many countries,

policymakers, health care providers and sex worker advocacy groups need to

understand different stakeholders attitudes towards sex workers and the legal status

of prostitution.

3.2. Aim of this review

The aim of the review is to explore the attitudes of different stakeholders toward sex

workers and prostitution law to shed light on the development of potential strategies

to improve the occupational health and safety of sex workers. An important

distinction in this review is the inclusion of a diverse and broad range of stakeholders.

Stakeholders of sex workers were identified through a preliminary search of the

literature, such as the law enforcement, professionals in health and social services,

clients of sex workers, sex workers, and the general public (Identifying stakeholders

process are described in Search strategy).

38
3.3. Methods

3.3.1. Search strategies and study selection process

Eight electronic databases, namely MEDLINE, PubMed, PsycInfo, CINAHL, the

British Nursing Index, the Web of Science, Scopus, and Social Work Abstract were

searched for studies published from 1986 to May 2016. The search of different

stakeholders attitudes was undertaken in two stages:

First stage search

The purpose of first stage search was to explore the types of stakeholders in the

literature. There was no restriction on the study population. Search terms included

medical subject headings (MeSH) terms and text words for ―sex worker‖ and terms

associated with ―attitude‖: (1) sex worker (―sex workers‖ OR ―prostitution‖ or

―prostitute*‖); (2) attitude (―attitude‖ or ―view‖ or ―opinion‖ or ―tolerance‖ or

―perception‖ or ―knowledge‖ or ―acceptance‖ or ―judg*‖ or ―belief*‖ or ―law‖ or

―legal‖ or ―criminalization‖ or ―decriminalization‖ or ― stigma‖ or ―discrimination‖).

Second stage search

After the first stage preliminary search, four main types of stakeholders were

identified, such as law enforcement officers, professionals in health and social

services, the clients of sex workers, and the general public. The second stage

included medical subject headings (MeSH) terms and text words for ―sex worker‖

and terms associated with ―attitude‖, in combination with terms associated with the

identified stakeholders:

1) law enforcement officers (―police‖ or ―policing‖ or ―law enforcement‖ or

―cops‖);

39
 2) professionals in health and social services (―health care worker‖ or ―health

professional‖ or ―health personnel‖ or ―health care provider‖ or ―nurs*‖ or

―doctor‖ or ―clinical staff‖ or ―health setting‖);

3) the clients of sex workers (―clients‖ or ―customer‖ or ―John‖);

4) and the general public (―public‖ or ―community‖ or ―population‖).

The full texts of potential citations were retrieved after a detailed examination of

abstracts. A manual search for additional literature was conducted through review of

the references of all eligible articles.

3.3.2. Inclusion and exclusion criteria

The criteria for studies to be included in this review were: (1) original articles

published in English; (2) full-text articles published in peer-reviewed journals in the

last 30 years; (3) articles focusing on the attitudes of stakeholders toward sex

workers or prostitution law. Exclusion criteria were: (1) studies aimed at exploring

sex workers experience; (2) research that focused on issues unrelated to stakeholders‘

attitudes toward sex workers or prostitution law; (3) conference abstracts or review

articles.

A total of 8,809 publications were identified from the electronic databases,

and fourteen additional records were identified through a manual search. Of these,

1,987 were removed due to duplication and the remaining 6,836 were screened by

examining the abstracts. Of these, 6,773 were excluded due to not meeting inclusion

criteria. The remaining 63 articles were then examined in detail. 14 articles were

further excluded due to one of the following reasons: full-text were not available

(Daniels, 2012; Garcia, 2014; Pajnik, 2009; Uchiyama, 1996), descriptive studies

(Larsen, 1996; O'Neill, Campbell, Hubbard, Pitcher, & Scoular, 2008), commentary

40
(Nolan, 2001), review of case files (Halter, 2010), questionnaire development and

validation (Busch, Bell, Hotaling, & Monto, 2002; Levin & Peled, 2011; S. P.

Sawyer & Metz, 2009), the studies focused on clients of sex workers characteristics

or clients experience (Holt & Blevins, 2007; R. Hong, 2008). Finally, a total of 49

studies were considered eligible and were included in this review (See Figure 3-1).

3.3.3. Assessing the quality of the included literature

The Mixed Methods Appraisal Tool (MMAT-Version 2011) developed by Pluye et al.

was used to assess the quality of the included studies (Pluye et al., 2011). The

validity and reliability of the tool have been verified (Pace et al., 2012). The MMAT

checklist includes two screening questions and 19 criteria for five types of studies: (1)

qualitative research (four criteria); (2) quantitative randomized controlled trials

(RCTs) (four criteria); (3) quantitative non-randomized studies (NRS) (four criteria);

(4) quantitative descriptive studies (four criteria); (5) and mixed methods studies

(three criteria assessing the quality of the integration of qualitative and quantitative

components). Screening questions are evaluating whether the study has clear

research questions and report data-collection. Each study type is appraised within its

methodological domain. However, appraising a mixed methods study involves three

sets: the qualitative set, the appropriate quantitative set, and the mixed methods set.

Criteria for appraising studies are checklist questions with possible answers

of ―Yes‖ for when the criterion is met, ―No‖ for when the criterion is not met, or

―Can‘t tell‖ for when there is insufficient information to make an assessment. In this

review, qualitative and quantitative studies are rated low quality when only one

criterion is met; moderate quality when two or three criteria are met; and high quality

when all the four criteria are met. For mixed methods studies, the overall quality is

41
determined by the component with the lowest quality (qualitative or quantitative).

Identification Records identified through database Additional records identified

searching through hand search
(n = 8809) (n = 14)

Records excluded
Records after duplicates removed (n = 6773)
(n = 6836) 1. Review articles (n=125)
2. Studies not relevant to
attitudes toward sex workers
(n=6615)
Screening

3. Commentary articles (n=25)

4. Other languages (n=8)
Records screened
(n = 6836)

Full-text articles excluded, with

reasons (n = 14)
1. Full-text was not
available (n=5)
Full-text articles assessed for eligibility 2. Client of sex workers‘
(n = 63) characteristics or
experience (n=2)
Eligibility

3. Descriptive study (n=3)

4. Questionnaire
development and
Studies to be included (n = 49) validation (n=3)
5. Review of case files
(n=1)
Included

Studies included in Studies included in Studies included in

qualitative synthesis quantitative combined qualitative
(n =9) synthesis and quantitative
(n =35) synthesis
(n =5)

Figure 3-1 The flow diagram on identifying the literature

42
3.3.4. Data extraction

The characteristics of the studies and the key findings were extracted and tabulated

according to the author(s), year of publication, the country where the study was

conducted, study design, participants, measurement(s) adopted, and main findings by

the first author and validated by the other two authors. The characteristics and key

findings of these studies are summarized in Appendices Table 3-1 and categorized

according to the stakeholders involved.

No formal statistical analysis was performed due to the heterogeneity of the

various measurements used to measure attitudes toward prostitution or prostitution

law in the included studies. For example, four studies measured the attitudes with a

single item on a 10-point scale: ―Please tell me whether you think prostitution can

always be justified, never be justified, or something in between‖. Six studies used or

selected items from the Attitudes Toward Prostitution Scale (ATPS), which was

developed by Steven Sawyer et al. (1998) (S. Sawyer, Rosser, & Schroeder, 1998) to

assess the sample basic attitudes toward prostitute or prostitution. Details of the

measurement are summarized in Appendices Table 3-1.

3.4. Results

3.4.1. Characteristics of the selected studies

There were nine qualitative studies, 35 quantitative studies, and five mixed methods

studies. Response rates were reported in 24 studies, ranging from 23.8% to 100%.

Among the included studies, 17 were conducted in North America, 11 in Asia, ten in

Europe, three in Africa, one in Australia, and seven involving two to 56 countries.

The majority of the studies addressed the attitudes of one type of stakeholder

(n=47/49), namely, law enforcement officers (n=7/49), professionals in health and

43
social services (n=8/49), the clients of sex workers (n=7/49), or the general public

(n=25/49). In addition, the views of multiple stakeholders were explored in two

studies. The characteristics of the studies and the key findings are summarized in

Appendices Table 3-1.

3.4.2. Quality of the included literature

The overall quality of the nine qualitative studies was considered as moderate quality,

with seven studies met two to three MMAT criteria. Only two studies met four

criteria and were considered to be of overall high quality. The most common

weaknesses were related to the sources of qualitative data and researchers‘ influence.

Six studies failed to address the reasons why potential respondents refused to

participate, and five studies did not explain researchers‘ influence during data

collection.

The overall quality of the 35 quantitative studies was considered as low to

moderate quality, with 11 studies met one MMAT criterion, 22 studies met two to

three criteria. Only two studies met four criteria and were considered to be of overall

high quality. Only six studies described the representative of the sample, with the

other 29 studies failed to report the reasons why eligible individuals refused to

participate. The reliability and validity of the measurements were not reported in

most of the studies (n=20). Only 15 studies achieved 60% or above response rate,

with the rest 20 studies either did not report response rate nor had a rate below 60%.

The overall quality of the five mixed-method studies was considered as

moderate quality, with four studies met two MMAT criteria. Only one study met one

criterion and was considered to be of overall low quality. The most common

weaknesses were related to reasons for the refusal (n=2) and researchers‘ influence

44
(n=4) of the qualitative component, and reasons of refusal (n=5) and unreported

response rate (n=4) of the quantitative component.

All of the published papers were included in this review regardless of their

quality. The details of the criteria of MMAT and the results of the appraisal of the

included studies are summarized in Appendices Table 3-2.

Attitudes towards sex workers and prostitution law are described below

according to the different types of stakeholders, including law enforcement officers,

professionals in health and social services, the clients of sex workers, and the general

public.

3.4.3. Attitudes toward sex workers

Generally speaking, there was a lack of consensus on the moral acceptance of sex

workers among different stakeholders.

A total of seven out of the 49 studies explored the attitude by law

enforcement officers. There was a lack of consensus on whether women engaged in

prostitution should be conceptualized as offenders or victims. The most common

negative attitudes among law enforcement officers toward sex workers were ―lower

class person‖ ―crack whores‖ (p.54) (Mentzer, 2010), who caused social problems

and public health concerns (Baker, 2007; Dodge, Starr-Gimeno, & Williams, 2005;

Giacopassi & Sparger, 1991; Guinto-Adviento, 1988). However, police officers in

the four studies, particularly the vice police officers who posed as decoy clients or

sex workers, expressed empathy, sympathy, sadness, and understanding toward sex

workers and viewed them as victims (Giacopassi & Sparger, 1991)}(Baker, 2007;

Dodge et al., 2005; Maguire & Nolan, 2011). The male police officers involved in

undercover work found their role to ―elicit an offer from prostitutes‖ distasteful (p.47)

45
(Giacopassi & Sparger, 1991). The female police officers who engaged in

undercover prostitution work, experienced stigma as well as violence when they

posed as sex workers (Baker, 2007; Maguire & Nolan, 2011), and viewed sex

workers as victims of society‘s larger social ills (Baker, 2007; Dodge et al., 2005;

Maguire & Nolan, 2011).

Similarly, a variety of attitudes toward sex workers were reported among

professionals in health care and social services in eight studies. Evidence indicated

that the majority of health care providers held high prejudice attitude toward sex

workers. They viewed sex workers as a threat to public health, or vectors of HIV, or

who should deserve mandatory HIV testing (Chan & Reidpath, 2007; Jayanna et al.,

2010; Melby, Boore, & Murray, 1992; Phrasisombath et al., 2012; Rogers et al.,

2014). However, positive attitudes toward sex workers was also reported in a cross-

sectional study of 56 countries, with 81.9% of the medical students considered FSWs

to be members of a vulnerable group, and 98.3% agreed that it was important to

provide them with care, regardless of the nature of their work (Nakagawa &

Akpinar-Elci, 2014). Social workers also expressed conflicting feelings towards

prostitution. In Israel, child protection officers considered prostitution to be an

acceptable and legitimate occupation, while they also viewed prostitution as

dangerous and harmful to the children of sex workers (Peled & Levin-Rotberg,

2013). Another study in the same country revealed that while the social workers

viewed prostitution as shameful, they were more likely to perceive adolescent girls

who were ―prostitutes‖ as victims and were reluctant to associate these girls with

prostitution (Peled & Lugasi, 2015).

Seven studies focused on the attitude of the clients towards sex workers.

Their conflicting attitudes towards prostitution echoed those of the law enforcement

46
officers and professionals in health and social sciences. Their negative attitudes

towards sex workers were documented in five studies in the U.S., Canada, South

Africa, and Scotland (Farley, Macleod, Anderson, & Golding, 2011; Kennedy, Klein,

Gorzalka, & Yuille, 2004; Potgieter, Strebel, Shefer, & Wagner, 2012; S. P. Sawyer &

Metz, 2009; Wortley, Fischer, & Webster, 2002). The clients viewed them as ―loose‖

women (p.196) (Potgieter et al., 2012) and drug users (Wortley et al., 2002), who

lowered the moral standard of the community (Farley et al., 2011). Notably, negative

attitudes toward prostitution have been linked in part to beliefs rape myth that sex

workers were un-rape-able, and they were entitled to do whatever they wanted to do

to sex workers (Farley et al., 2011). Some held certain beliefs such as sex workers

enjoy their work and they genuinely like men (Preston & Brown-Hart, 2005; S. P.

Sawyer & Metz, 2009). Yet, two of these five studies also described clients as feeling

empathetic and understanding toward sex workers (Farley et al., 2011; S. P. Sawyer

& Metz, 2009). Nearly half of the clients in the U.S. (46%) and Scotland (50%)

(Farley et al., 2011; S. P. Sawyer & Metz, 2009) agreed that ―prostitutes were

victimized by pimps‖, and many felt guilty or ashamed after purchasing sex (Farley

et al., 2011).

Over half (n=25) of the included studies focused on the attitude of the general

public towards sex workers. The attitudes of the general public largely resembled

those of other stakeholders, with opinions towards prostitution being wide-ranging

and complex. Sixteen out of the 25 studies reported negative attitudes toward sex

workers in the U.S., Canada, Russia, Norway, Sweden, Finland, Japan, Australia,

China, Spain, and South Africa (Cotton, Farley, & Baron, 2002; Kotsadam &

Jakobsson, 2011, 2014);(Cao & Stack, 2010; Jakobsson & Kotsadam, 2011; Morton,

Klein, & Gorzalka, 2012; Otsuki & Hatano, 2009; Räsänen & Wilska, 2007;

47
Shdaimah, Kaufman, Bright, & Flower, 2014);(Alikhadzhieva, 2009; Basow &

Campanile, 1990; Long, Mollen, & Smith, 2012; Moore, 1999; Pudifin & Bosch,

2012; Valor-Segura, Expósito, & Moya, 2011; Zheng et al., 2011). Two cross-

national studies on the value of sex workers indicated that the majority of the

population in these countries, especially among Muslim populations, alleged that

prostitution was never justifiable (Chon, 2015; Stack, Adamczyk, & Cao, 2010).

Evidence also supported the shared opinion that there was a general culture of

distaste and disrespect toward street sex workers (Sanders & Campbell, 2007), they

were more strongly condemned than indoor sex workers (Morton et al., 2012).

However, the general public from three studies in Tanzania, Thailand, and the UK

showed a relatively higher level of tolerance towards prostitution (Peracca, Knodel,

& Saengtienchai, 1998; Roberts, Sanders, Myers, & Smith, 2010; Sagar & Jones,

2013; Wamoyi, Fenwick, Urassa, Zaba, & Stones, 2011). Prostitution in Tanzania is

considered a social norm (Wamoyi et al., 2011), and it is not uncommon in Thailand

for families to contract their daughters to brothels (Peracca et al., 1998). In the UK,

where neighbourhoods are affected by sex work, 46.8% of community members

expressed empathy and 57.1% were concerned about the safety of sex workers

(Sagar & Jones, 2013).

Public attitudes toward prostitution also could change over time. A

longitudinal study has provided information about the effect of time trends on the

public‘s tolerance of prostitution in the U.S. (Cao & Stack, 2010). It concluded that

the public moved toward greater tolerance of prostitution in the U.S. over a 20-year

period (1981-2000), with respondents who considered prostitution as never justified

decreasing from 64% in 1981 to 47.9% in 2000.

48
3.4.4. Attitudes toward prostitution laws

Alongside with the mixed attitudes towards prostitution, law enforcement officers

and the general public also expressed conflicting feelings towards policing

prostitution. Two studies indicated that the majority of police officers and criminal

justice practitioners opposed decriminalizing or legalizing prostitution (Mentzer,

2010; M. Smith, Muftić, Deljkić, & Grubb, 2015). However, police officers were

under no illusion that prostitution could be eliminated (Giacopassi & Sparger, 1991;

Guinto-Adviento, 1988; Mentzer, 2010). They enforced the law selectively and

considered selective toleration to be the best strategy to police prostitution. For

instance, they would be less likely to interfere with prostitution if it occurred in a

private place (Mentzer, 2010), and only take action upon orders from their

supervisors (Guinto-Adviento, 1988).

Public attitudes toward the legal status of prostitution were explored. Seven

studies reported that the general public in the U.S., Russia, Sweden, Norway, South

Africa, and Australia opposed the legalization of prostitution and called for imposing

criminal liability on clients (Alikhadzhieva, 2009; Jakobsson & Kotsadam, 2011;

Kotsadam & Jakobsson, 2011; May, 1999; Moore, 1999; Pudifin & Bosch, 2012;

Shdaimah et al., 2014). In Sweden, where selling sex is legal, 58.7% of the general

public wanted to prohibit the selling of sex (Kotsadam & Jakobsson, 2011). In

contrast, the general public in Canada and the UK expressed favourable attitudes

toward the legalization of prostitution (Morton et al., 2012; Sagar & Jones, 2013).

They regarded prostitution as an acceptable and legitimate occupation, and called for

the laws on prostitution to improve the occupational safety of sex workers (Morton

et al., 2012).

Attitudes towards the establishment of managed zones or ―red light

49
districts‖ (Districts where prostitution is located) for prostitution was explored

among different stakeholders in the UK and Hong Kong (Bellis et al., 2007; Lai,

Leung, Siu, & Thadani, 2015). In the UK, respondents believed that a managed zone

would improve the safety of street sex workers, reduce the number of street sex

workers outside the zone, improve access to service, and lead to better policing and

regulation. A large majority (96%) of the street sex workers strongly preferred to

work in such a zone for safety reasons (Bellis et al., 2007). In Hong Kong, the

majority of the respondents opposed the idea of setting up red-light districts. NGO

staff and sex workers were concerned about the possibility of labelling and social

exclusion, while the police believed that red-light districts would increase crimes

related to sex work (Lai et al., 2015). Concerning choosing a location or zone for

red-light districts, community members opposed the idea of having such zone near

their residential area and strongly pronounced ―not in my backyard‖ and ―away from

residential districts‖ (Bellis et al., 2007; Lai et al., 2015), suggesting that a deep-

rooted opposition to prostitution exists in the community.

3.5. Discussion

This systematic review included studies conducted in the last 30 years on the

attitudes of different stakeholders toward prostitution. The discussion of the main

findings of this review can be organized into three categories: the polarized attitudes

of stakeholders towards sex work, the polarized attitudes of stakeholders toward

legalization of prostitution, and the occupational health and safety of sex workers.

Polarized attitudes of stakeholders towards sex workers

This review revealed that there was no consensus in the attitude towards sex workers.

50
Different stakeholders, including those within the same group, and individuals held

conflicting and inconsistent levels of tolerance, and ambivalent and even

contradictory attitudes. They viewed sex workers as both victims and offenders; they

were tolerant of prostitution, but largely limited their tolerance to the indoor sex

worker. They viewed prostitution as ―disgusting‖ and ―immoral‖ (p.504) (Zheng et

al., 2011), and complained about social and public health problems that it caused,

while they showed empathy and understanding toward sex workers and were

concerned about their safety. They favoured the idea of providing a safe place for sex

workers, while maintaining that the selection of the location should follow the ―not

in my backyard‖ principle.

Polarized attitudes of stakeholders towards the legalization of prostitution

There was a lack of consensus among the different stakeholders on the legal status of

prostitution. Despite the worldwide advocacy of decriminalization as the best way to

safeguard the occupational health and safety of sex workers (Amnesty International,

2015; Decker et al., 2015), not everyone supported the decriminalization or

legalization of prostitution in their countries, and some even called for tougher

punishment (Kotsadam & Jakobsson, 2011). Given the fact that different

stakeholders have a potential impact on laws on prostitution, which can in turn affect

the occupational risks of sex workers, more empirical studies should be conducted

on the attitudes of different stakeholders and the impact of their attitudes on the sex

workers‘ health and safety, and on the implications of the establishment or

enforcement of laws on prostitution.

51
Occupational health and safety of sex workers

Regardless of the legal status of prostitution, sex workers deserve respect and protect

the human dignity and human rights. Law enforcement officers, health care

providers, the clients of sex workers, and the general public worldwide, are key

stakeholders in shaping the day-to-day life of sex workers. Their negative attitudes

toward prostitution might lead to increased misconduct, unequal treatment, and

increased violence. Therefore, it is worthwhile to look into strategies that support the

well-being of sex workers.

1) Reducing stigmatizing attitudes among law enforcement officers

Particular attention should be given to law enforcement officers since they have

more chances than most people to interact with sex workers and implement laws

against sex workers. Despite the significant amount of evidence that describes police

harassment and abuse of sex workers (Willis et al., 2014), findings from this review

highlighted that police officer, especially those who have posed as decoy clients or

sex workers, usually showed understanding, empathy, and sympathy attitudes

towards prostitutes. This finding is consistent with the stigma research that suggests

knowledge and experience with a stigmatized population are linked to a more

positive attitude toward these people (Scior, 2011; Valor-Segura et al., 2011). Thus,

increasing the knowledge and understanding of the sex industry among law

enforcement officers could potentially reduce their negative attitudes toward

prostitution and inappropriate treatment when interacting with sex workers.

Innovation and successful partnerships between sex workers and police in

several countries have been launched and demonstrated effective in reducing

stigmatizing attitudes and police harassment toward sex workers. For example, in

52
India, the Vikas Jyot Trust (VJT) fostered a supportive environment for sex workers

through providing the police with informal meetings with sex workers and

sensitizing them on sex workers‘ needs and concerns (Biradavolu, Burris, George,

Jena, & Blankenship, 2009). In Australia, the cooperation between Resourcing

Health and Education in the Sex Industry (RhED) Ugly Mugs program and the local

police provided a non-judgmental environment for sex workers and increased the

number of reported of crimes against sex workers to the police (Tenni, Carpenter, &

Thomson, 2015). Given the success of these programs, this review calls for more

interventions to promote the communication between the police and sex workers.

2) Reducing stigmatizing attitudes among health care professionals

More evidence showed that the negative attitudes of health care providers did not

differ from other groups, their stigmatized attitude could affect healthcare delivery

for these marginalized population and further result in sex workers‘ avoidance of

treatment and deterioration in their health (Rogers et al., 2014). Health care

providers should be aware that their negative attitude toward sex worker might

translate into discriminatory behaviours that influencing patients‘ equal access to

health care. Several studies highlighted the need for job-related training aimed at

improving knowledge, attitudes and counselling skills in the delivery of healthcare to

this vulnerable population among health care professionals and students (Jayanna et

al., 2010; Melby et al., 1992; Nakagawa & Akpinar-Elci, 2014; Phrasisombath et al.,

2012; Rogers et al., 2014).

Interventions on attitudes training for other marginalized populations may

shed lights on the development of intervention programmes to reduce sex work-

related stigma among health care providers. Plenty studies are focusing on reducing

53
health care providers‘ stigmatizing attitudes toward people living with HIV/AIDS,

multiple approached could be adopted, such as delivering HIV/AIDS-related

information, providing communicating skills with patients, discussing medical ethics

and legal issues, addressing the stigma and discrimination of HIV, contacting with

patients (Mockiene et al., 2011). Besides, organizations support, such as identifying

staff needs and providing counselling/support is also essential in improving health

care providers‘ willingness to treat these marginalized patients and job satisfaction.

3) Reducing stigmatizing attitudes in the community

Although the study conducted in the U.S. informs us the increasingly more tolerant

attitudes toward prostitution (Cao & Maguire, 2013), the strong cultural and social

stigma against sex workers is difficult to eradicate. Even in countries where

prostitution is legal, society‘s negative perception of prostitution remains unchanged

(Begum, Hocking, Groves, Fairley, & Keogh, 2013). Clients‘ violence could also

thrive where beliefs such as sex workers cannot be raped (Penfold, Hunter, Campbell,

& Barham, 2004). Therefore, a friendly and supportive community environment is

essential for sex workers well-being. Interventions in India showed that community

mobilization was successful in reducing social stigma toward sex workers (I. Basu et

al., 2004). It facilitated the social acceptance of sex workers through increasing

awareness of sex workers‘ health needs, protecting their human rights, providing

health-related resources, and advocating changes in societal attitudes toward

sexuality and sex work (I. Basu et al., 2004). The replicability of the programs

should be tested in future programs and interventions in different countries or legal

systems.

54
3.6. Limitations

There are several limitations in the present systematic review, and the findings

should be interpreted with caution. First, the evidence is dominated by attitudinal

surveys with convenience samples. Moreover, over half of the included studies did

not report a response rate, and the sample size varied considerably from study to

study. All these factors could limit the generalizability of the findings. Second,

approximately half of the included studies adopted a self-administered survey or a

mail or internet-based survey, and the respondents may not have shared their true

feelings. This review cannot be free from the possibility of social desirability bias.

Third, this review only included peer-reviewed articles, while the grey literature

relating to this topic and unpublished surveys were not explored. This review may be

susceptible to publication bias. Lastly, this review only included studies published in

English. Therefore, it is possible that we have missed studies on this topic in non-

English language journals.

3.7. Summary

To our knowledge, this is the first review of attitudes towards prostitution among

different stakeholders in the last three decades. The current attitudes of different

stakeholders appear to be largely similar in their ambivalence, inconsistency, and

even contradictory views toward sex workers and prostitution laws. Although the

debate over prostitution laws seems unlikely to end in the foreseeable future, this

review indicates that interventions need to be implemented among different

professional groups who may affect the well-being of sex workers.

55
3.8. Recommendations for future research

The perceptions of different stakeholders could have a powerful influence on the

lives of sex workers and a significant impact on their health and health-seeking

decisions. Those who do not accept this profession may hold judgmental attitudes

toward sex workers, subsequently, result in further marginalization of sex workers.

Regarding the multiple health care needs of sex workers, it is necessary to include

the voices of sex workers themselves to understand their health care services

experience. It was then decided to lunch a review to understand the barriers and

facilitators to the accessing of health services by sex workers.

56
 Chapter 4 Review of literature (III)

Barriers and facilitators to the accessing of health services by sex workers

[Link] of the review

[Link] of this review

[Link]

4.3.1. Search strategies and study selection process

4.3.2. Inclusion and exclusion criteria

4.3.3. Assessing the quality of the included literature

4.3.4. Synthesis of the findings of the study

[Link]

4.4.1. Characteristics of the selected studies

4.4.2. Barriers to accessing health services

4.4.3. Facilitators to accessing health services

[Link]

[Link]

[Link]

*Content of this chapter is published (partial content included in this chapter):

Ma, P. H., Chan, Z. C., & Loke, A. Y. (2017). The socio-ecological model approach

to understanding barriers and facilitators to the accessing of health services by sex

workers: a systematic review. AIDS and Behavior, 21(8), 2412-2438.

57
4.1. Background of the review

Timely and quality health care could be considered as a basic human right, and good

access to health services could contribute to improvements in health outcomes.

However, inequities in access to health care persist, with marginalized and

stigmatized populations facing particular difficulties with gaining access to health

care (Burns, Imrie, Nazroo, Johnson, & Fenton, 2007; Hatzenbuehler, Phelan, &

Link, 2013; Waidmann & Rajan, 2000). Such limitations could lead to serious health

consequences and even death (Singh, Azuine, & Siahpush, 2013).

Sex workers are among the most marginal and vulnerable groups in society.

Sex workers have multiple health care needs in areas such as the prevention and

treatment of HIV/STIs, sexual and reproductive health, safe abortion services, the

treatment of physical abuse, and substance abuse rehabilitation. However, there is a

growing body of literature indicating that sex workers are reluctant to seek health

care (Alexander, 1998; Gomez et al., 2010; Lau, Mui, et al., 2007). Instead, they use

self-prescribed medications, or visit illegal clinics (Alexander, 1998; Gomez et al.,

2010; Lau, Mui, et al., 2007).

Health-seeking behaviours and access to health services of vulnerable populations

Health-seeking behaviours and access to health services are complex issues. Reviews

of literature have reported that various groups of marginalized and vulnerable

population groups including those living with HIV (Deblonde et al., 2010;

Govindasamy, Ford, & Kranzer, 2012), suffered from mental illness (Gulliver,

Griffiths, & Christensen, 2010), and drug users (Wolfe, Carrieri, & Shepard, 2010)

face significant challenges in accessing health services. Reviews have reported on

these populations‘ avoidance or delay in treatment attributable to multi-level factors.

58
These factors include the lack of knowledge of health service (Gulliver et al., 2010),

perception of risk (Deblonde et al., 2010), and internalized stigma and fear of

disclosure (Deblonde et al., 2010; Govindasamy et al., 2012; Gulliver et al., 2010) at

the individual level as barriers. Other factors are relating to the reliance on family

and friends (Govindasamy et al., 2012; Gulliver et al., 2010) at the interpersonal

micro-level; and social stigma (Govindasamy et al., 2012; Gulliver et al., 2010;

Wolfe et al., 2010) at the community meso-level. At the socio-policy / laws macro-

level, there are barriers such as discrimination in health care settings (Deblonde et al.,

2010; Wolfe et al., 2010), breach of privacy (Wolfe et al., 2010), and lack of

accessibility (Deblonde et al., 2010; Gulliver et al., 2010) at the health organization

exo-level; and the lack of available universal testing or free treatment (Deblonde et

al., 2010; Wolfe et al., 2010). However, there is no systematic review been conducted

that explored the barriers and facilitators to accessing health services among sex

workers.

Besides the epidemiology information on disease prevalence and the pressing

healthcare needs of sex workers, it is essential for health policymakers, health care

professionals, and non-governmental advocacy groups to have an understanding of

the factors that impede sex workers from accessing proper health services or that

motivate them to utilize such services. Only then will it be possible to devise

services that are appropriate and acceptable to sex workers and that protect and

promote their physical, sexual, and mental health.

The social-ecological model is one that is widely accepted and used to better

understand the health behaviours of individuals (Sallis, Owen, & Fisher, 2015)

(Figure 4-1). It considers the dynamic interplays between individuals and their

environments as determinants of health-related behaviour. The social-ecological

59
 Policy
(national, provincial/territorial,
local laws and policy)

Community
(relationships and communications
between organizations and
institutions)

Institutional
(schools, health care administration,
businesses, faith based
organizations, institutions)

Interpersonal
(families, friends, social
networks)

Intrapersonal
(attitudes, beliefs,
knowledge, behaviors)

Figure 4-1 The Social Ecological Model

Source: Adapted from the Centers for Disease Control and Prevention (CDC), The Social Ecological
Model, [Link]
[Link]
(Retrieved December 13, 2016).

model acknowledges that an individual‘s behaviour is shaped through multilevel

factors that include the intrapersonal, interpersonal, institutional, community, and

policy levels (Sallis et al., 2015). The social-ecological model is applied in this

review to offer a holistic understanding of the health-seeking behaviours of sex

workers and their access to health care services.

4.2. Aim of this review

This study is a systematic review of both qualitative and quantitative studies on the

60
experiences of sex workers in seeking health care and their perceptions of the

barriers and facilitators that they encounter when attempting to access such services.

The social-ecological model is applied in this review.

4.3. Methods

4.3.1. Search strategies and study selection process

The following 10 electronic databases were searched for studies published from the

inception of the database to August 2016, which explore the health-seeking

experiences of sex workers: Cochrane Library, MEDLINE, EMBASE, PubMed,

PsycInfo, CINAHL, the British Nursing Index, Web of Science, Scopus, and

Proquest Dissertation & Theses. These databases contain published manuscripts in

the disciplines of health and biomedical sciences, social sciences, psychology, and

nursing, that provide insights to the specific topic of interest. The search included

medical subject headings (MeSH) terms and text words for ―sex worker‖ and terms

associated with ―health care service‖, ―barriers‖ and ―facilitators‖: (1) sex worker

(―sex workers‖ OR ―prostitution‖ or prostitute*); (2) health care service (―health care‖

or ―health service‖ or ―treatment‖ or ―health access‖); and (3) experience

(―experience‖ or ―stigma‖ or ―discriminat*‖ or ―difficult*‖ or ―challenge‖ or

―concern‖ or ―barrier‖ or ―attitude‖ or ―perception‖ or ―facilitator‖ or ―motivat*‖).

These terms were generated by examining the terminologies used in the review

papers and other relevant literature. The full-text versions of potential citations were

retrieved for a detailed examination. A manual search for additional literature was

made from the reference lists of all of the eligible articles.

61
4.3.2. Inclusion and exclusion criteria

The criteria for studies to be included in this review were: (1) articles focusing on the

experience of sex workers in seeking health care and their perceptions of the barriers

or facilitators to accessing health services; (2) full-text articles; and (3) original

articles published in English. Conference abstracts or literature review articles were

excluded.

A total of 3,852 publications were identified from the electronic databases. A

total of 1,159 publications was removed due to duplication, and the remaining 2,693

abstracts were screened. Of these, 2,656 publications were excluded on exclusion

criteria. The full texts of the remaining 37 articles were examined in detail and nine

studies were further excluded. Finally, a total of 28 studies were considered eligible

and were included in this review. In addition, two relevant studies were retrieved

from a manual search of the reference lists of the included studies. Hence, a total of

30 studies were included in this review. Of these, 27 were published in peer-

reviewed journals, and three were dissertation theses. The flowchart of the literature

search and selection process is summarized in Figure 4-2.

62
 Records identified through database Additional records identified through hand
Identification search
searching
(n = 3852) (n = 2)

Records excluded
(n =2656)
Records after duplicates removed 1. Literature review articles
(n = 2693) (n=37)
2. Studies not relevant to
sex workers experience
of health care service
Screening

(n=2618)
3. Commentary articles
Records screened (n=1)
(n = 2693)

Full-text articles excluded, with

reasons (n =9)
Full-text articles assessed for eligibility 1. Abstract only (n=2)
Eligibility

(n =37) 2. Studies not focused on

barriers and facilitators of
health care utilization of sex
workers (n=7)

Full-text articles assessed for eligibility (n =28+2)

Included

Studies included in Studies included in Studies included in

qualitative synthesis quantitative synthesis combined qualitative and
(n =11) (n =9) quantitative synthesis
(n =10)

Figure 4-2 The flow diagram on identifying the literature

63
4.3.3. Assessing the quality of the included literature

The quality of the selected studies was assessed before inclusion in this review. The

quantitative studies were assessed using the critical appraisal guide outlined by

Crombie for descriptive surveys (Crombie & Harvey, 1997). The ―Crombie Criteria‖

contains 11 questions with possible answers of ―Yes‖, ―No‖, or ―Unclear‖ to assess

the research design, selection of the subjects and representatives, the reliability of the

measurement, and the statistical analysis. The quality of the qualitative studies was

assessed using the Critical Appraisal Skills Programme (CASP) checklists for

qualitative studies (CASP), which assess the rigour, credibility, and relevance of the

qualitative study. CASP contains ten items, with item 1 to 9 were questions with

possible answers of ―Yes‖, ―No‖, or ―Can‘t tell‖. Item ten requires the discussion

among assessors. Explanatory hints were provided under each question. For mixed-

method studies, both sets of criteria were adopted.

The overall quality of the 19 quantitative studies or quantitative component

of the mixed-method studies were considered as moderate quality, with 17 of the

studies meeting four to seven criteria of the Crombie's critical appraisal guide. Only

two studies met eight or nine of the criteria and were considered to be of overall

good quality. Only one study adopted random sampling method; with the other 18

studies could not be considered as free from selection bias, and the

representativeness of their sample populations was questionable. The calculation of

sample size was not reported in the majority of the studies (n=18). Only six studies

achieved a response rate of 70% or higher, but 13 studies did not report the response

rate. The reliability and validity of the measurements were not reported in most of

the studies (n=15). Details of the appraisal of the quality of these studies are listed in

Appendices Table 4-1.

64
 The 21 qualitative studies or the qualitative component of the mixed-method

studies were assessed to be of moderate quality, with the majority of the studies

meeting three to five CASP criteria. Only four studies met seven CASP criteria and

were considered to be of good overall quality. All 21 studies were considered

important in contributing qualitative evidence to sex workers health-seeking

experience (item 10). The most common weaknesses were related to the justification

of the research design (not reported in 17 studies), the discussion of non-participants

(not reported in 20 studies), data saturation (not reported in 15 studies), the

relationship between the researcher and the participants (not reported in 20 studies),

and the rigorousness of the data analysis (not reported in 17 studies). No studies

were excluded on the basis of the quality of the methodology.

4.3.4. Synthesis of the findings of the study

The characteristics of the studies and key findings were extracted and tabulated

according to author(s), year of publication, country where the study was conducted,

aims of the study, study design, sampling method, participants, types of health care

services, and main findings by the first author and validated by the other two authors.

The extracted data were analysed by adopting the inductive approach according to

the Socio-ecological Model. The two main barriers and facilitators factors of sex

workers in seeking health care were categorized into the intrapersonal, interpersonal,

institutional, community, and policy levels. The characteristics and key findings of

these studies are summarized and categorized in Appendices Table 4-2.

65
4.4. Results

4.4.1. Characteristics of the selected studies

There were 11 qualitative studies, nine quantitative studies, and 10 mixed-methods

studies. The studies were published between 2003 to 2016. Most were conducted in

North America (n=10), followed by Asia (n=9), Africa (n=7), and European

countries (n=4). The size of the sample in each study varied markedly from nine to

2,220, and the total was 10,787. The response rate was reported in only six studies,

and ranged from 80% to 98.6%.

The majority of the studies addressed the health-seeking experiences of

FSWs (n=23), with five studies exploring the experiences of different types of sex

workers, including FSWs, MSWs, and transgender sex workers. Two studies also

included other groups of people at an elevated risk of contracting HIV, such as men

who have sex with men (MSM).

Twelve studies focused on the general health care-seeking experiences of sex

workers, sixteen investigated their experiences with sexual and reproductive health

services, and one explored their experiences with both general health services and

sexual health services. One study addressed the experiences of sex workers seeking

treatment for drug addictions. Details of the characteristics and key findings of these

studies are summarized in Appendices Table 4-2.

4.4.2. Barriers to accessing health services

All of the 30 studies included in this review described the barriers encountered by

sex workers to seeking health services (Appendices Table 4-3). The barriers to

accessing to health services are discussed according to intrapersonal, interpersonal,

institutional, community and policy levels.

66
Barriers at the intrapersonal level

Twenty-five studies described the barriers to accessing health services at the

intrapersonal level (Basnyat, 2017; Beattie et al., 2012; Chakrapani et al., 2009;

Folch, Lazar, Ferrer, Sanclemente, & Casabona, 2013; Ghimire, Smith, & van

Teijlingen, 2011; Y. Hong et al., 2012; Jeal & Salisbury, 2004; Kimani, 2014; King,

Maman, Bowling, Moracco, & Dudina, 2013; Kurtz, Surratt, Kiley, & Inciardi, 2005;

Marlow, Shellenberg, & Yegon, 2014; Mtetwa, Busza, Chidiya, Mungofa, & Cowan,

2013; Ngo et al., 2007; Nguyen, Venne, Rodrigues, & Jacques, 2008; Phillips &

Benoit, 2005; Phrasisombath et al., 2012; Porras et al., 2008; Savva, 2013; Scorgie et

al., 2013; Shannon, Bright, Duddy, & Tyndall, 2005; F. M. Smith & Marshall, 2007;

Surratt, O‘Grady, Kurtz, Buttram, & Levi-Minzi, 2014; Underhill et al., 2014; Varga,

2012; Y. Wang et al., 2011). These included a lack of information about

diseases/available services, the fear of medical treatment, the costs, and the lack of

personal capacity. Sex workers often have limited health information (Basnyat, 2017;

Ngo et al., 2007; Underhill et al., 2014) or low perception of the risks of HIV/STIs

(Y. Hong et al., 2012; Ngo et al., 2007). They were also plagued by numerous fears:

feared public exposure (Basnyat, 2017; Ghimire et al., 2011; Y. Hong et al., 2012;

Jeal & Salisbury, 2004; Kimani, 2014; King et al., 2013; Nguyen et al., 2008;

Phillips & Benoit, 2005; Porras et al., 2008); feared being infected with HIV (Beattie

et al., 2012; Ngo et al., 2007; Phillips & Benoit, 2005; Underhill et al., 2014; Varga,

2012; Y. Wang et al., 2011), and feared the side-effects of potential treatments

(Basnyat, 2017; Shannon et al., 2005). Financial constraints further pushed them

outside of the health care system (Beattie et al., 2012; Ghimire et al., 2011; Mtetwa

et al., 2013; Ngo et al., 2007; Phrasisombath et al., 2012; Scorgie et al., 2013;

Underhill et al., 2014; Varga, 2012). Moreover, the capacity of the sex workers to

67
take care of themselves was undermined by a number of factors, such as substance

abuse (Chakrapani et al., 2009; Kurtz et al., 2005; Savva, 2013; Surratt et al., 2014;

Underhill et al., 2014; Varga, 2012), street life (Kurtz et al., 2005), mental health

status (Kurtz et al., 2005), sex work (Chakrapani et al., 2009), and ability to adhere

to daily regimes (Shannon et al., 2005).

Barriers at the interpersonal level

Six studies identified barriers at the interpersonal level to accessing health services

(Basnyat, 2017; Chakrapani et al., 2009; Ghimire et al., 2011; Marlow et al., 2014;

Ngo et al., 2007; F. M. Smith & Marshall, 2007). These included a lack of social

support and peer influence. Sex workers reported that they would face domestic

violence or be forced out of their home if found to be HIV-positive (Chakrapani et al.,

2009; F. M. Smith & Marshall, 2007), and that their competitiveness in the sex

industry would be severely impaired (Chakrapani et al., 2009). The informal network

of sex workers was a primary source of health information, as sex workers often

sought information from their peers rather than from health professionals (Basnyat,

2017; Marlow et al., 2014; Ngo et al., 2007).

Barriers at the institutional level

Twenty-five studies identified the following as constituting the institutional barriers:

the poor quality of care, inadequate and inconvenient services, and types of clinics

(Basnyat, 2017; Beattie et al., 2012; Chakrapani et al., 2009; Duff et al., 2016; Folch

et al., 2013; Ghimire et al., 2011; Jeal & Salisbury, 2004; Kimani, 2014; King et al.,

2013; Kurtz et al., 2005; Lafort et al., 2016; Marlow et al., 2014; Mtetwa et al., 2013;

Ngo et al., 2007; Nguyen et al., 2008; Phillips & Benoit, 2005; Phrasisombath et al.,

68
2012; Porras et al., 2008; Rosenheck, Ngilangwa, Manongi, & Kapiga, 2010; Savva,

2013; Scorgie et al., 2013; Shannon et al., 2005; F. M. Smith & Marshall, 2007;

Underhill et al., 2014; W.-C. Wong, 2003).

The findings relating to institutional-level barriers to the use of health

services were noteworthy. The sex workers anticipated or had previously

experienced poor attitudes and treatment from health care providers (Basnyat, 2017;

Beattie et al., 2012; Chakrapani et al., 2009; Duff et al., 2016; Folch et al., 2013;

Ghimire et al., 2011; Jeal & Salisbury, 2004; Kimani, 2014; King et al., 2013;

Marlow et al., 2014; Mtetwa et al., 2013; Ngo et al., 2007; Phillips & Benoit, 2005;

Phrasisombath et al., 2012; Porras et al., 2008; Savva, 2013; Scorgie et al., 2013; F.

M. Smith & Marshall, 2007; Varga, 2012), and they felt that their right to privacy

and confidentiality was being violated in health care settings (Basnyat, 2017;

Chakrapani et al., 2009; Ghimire et al., 2011; Lafort et al., 2016; Ngo et al., 2007;

Scorgie et al., 2013). Overwhelmingly, inadequate and inconvenient services were

considered barriers to accessing health services (Basnyat, 2017; Beattie et al., 2012;

Duff et al., 2016; Folch et al., 2013; Ghimire et al., 2011; Y. Hong et al., 2012; Jeal

& Salisbury, 2004; Kimani, 2014; Kurtz et al., 2005; Lafort et al., 2016; Mtetwa et

al., 2013; Ngo et al., 2007; Nguyen et al., 2008; Phrasisombath et al., 2012; Porras et

al., 2008; Savva, 2013; Scorgie et al., 2013; Shannon et al., 2005; F. M. Smith &

Marshall, 2007; Underhill et al., 2014; Varga, 2012; W.-C. Wong, 2003). Sex

workers felt that health agencies failed to provide them with services tailored to their

multiple health care needs, such as treatment for substance use, hepatitis C, mental

health care, as these were not available at the clinics or hospitals that they visited

(Beattie et al., 2012; Kurtz et al., 2005; Porras et al., 2008; F. M. Smith & Marshall,

2007; Underhill et al., 2014). Sex workers were also frustrated by inconvenient

69
opening hours (Ghimire et al., 2011; Nguyen et al., 2008), long waiting times

(Basnyat, 2017; Beattie et al., 2012; Folch et al., 2013; Ghimire et al., 2011; Jeal &

Salisbury, 2004; Lafort et al., 2016; Mtetwa et al., 2013; Ngo et al., 2007;

Phrasisombath et al., 2012; Porras et al., 2008; Savva, 2013; Scorgie et al., 2013),

inconvenient locations (Beattie et al., 2012; Jeal & Salisbury, 2004; Kimani, 2014;

Kurtz et al., 2005; Mtetwa et al., 2013; Phrasisombath et al., 2012; Scorgie et al.,

2013; Underhill et al., 2014), and absence of user-friendly appointment systems that

they encountered (Jeal & Salisbury, 2004; Nguyen et al., 2008; Shannon et al., 2005).

Sex workers experienced discomfort with the types of clinics that they visited

(Nguyen et al., 2008; Porras et al., 2008; Shannon et al., 2005; W.-C. Wong, 2003),

and feared being labelled as sex workers at STI clinics (Ngo et al., 2007; Porras et al.,

2008; W.-C. Wong, 2003).

Sex workers in some developing countries faced greater barriers to accessing

health services. Limited laboratory services and shortage of medicine were cited as

key obstacles to health services in India, Guatemala, and Africa (Beattie et al., 2012;

Lafort et al., 2016; Porras et al., 2008; Scorgie et al., 2013). These challenges further

worsened by the corruption in health care settings, and sex workers needed to pay

bribes to health care providers to receive care for HIV/STIs (Beattie et al., 2012;

Lafort et al., 2016; Phrasisombath et al., 2012). All contributed to their reluctance to

utilize health services when they needed to do so.

Barriers at the community level

Being socially stigmatized is a major fear of sex workers. A total of sixteen studies

showed that across countries with different prostitution laws or various levels of

development, there was no difference on the social stigma against sex work

70
contributed to sex workers‘ reluctance to seek appropriate treatment (Beattie et al.,

2012; Chakrapani et al., 2009; Y. Hong et al., 2012; Kimani, 2014; King et al., 2013;

Lazarus et al., 2012; Mtetwa et al., 2013; Ngo et al., 2007; Rosenheck et al., 2010;

Scorgie et al., 2013; Shannon et al., 2005; F. M. Smith & Marshall, 2007; Surratt et

al., 2014; Underhill et al., 2014; Varga, 2012; Y. Wang et al., 2011). Specifically, they

were concerned about the stigma associated with HIV/STIs (Beattie et al., 2012;

Chakrapani et al., 2009; Y. Hong et al., 2012; King et al., 2013; Ngo et al., 2007;

Shannon et al., 2005; Surratt et al., 2014; Y. Wang et al., 2011), drug use (F. M.

Smith & Marshall, 2007; Underhill et al., 2014; Varga, 2012), and sex work (Beattie

et al., 2012; Chakrapani et al., 2009; Kimani, 2014; Mtetwa et al., 2013; Rosenheck

et al., 2010; Surratt et al., 2014; W.-C. Wong, 2003).

Barriers at the policy level

While information about barriers at the policy level and the uptake of health services

among sex worker was limited, one study identified a policy that created a barrier to

the accessing of health services (Kurtz et al., 2005). In the United States, proof of

legal identity and citizenship status is required in health care settings, which has

excluded sex workers who have entered the country illegally from seeking health

services. Also, prostitution was illegal in the United States, and the fear of being

arrested also hindered them from accessing health services (Kurtz et al., 2005).

4.4.3. Facilitators to accessing health services

Twenty–two of the 30 studies included in this review described the facilitators for

sex workers to seeking health services (Appendices Table 4-4). The facilitators to

accessing health services are also discussed according to intrapersonal, interpersonal,

71
institutional, community and policy levels.

Facilitators at the intrapersonal level

Nine studies reported on facilitators at the intrapersonal level that encourage access

to health services (Beattie et al., 2012; Chakrapani et al., 2009; Marlow et al., 2014;

Porras et al., 2008; Rosenheck et al., 2010; Surratt et al., 2014; Underhill et al., 2014;

Varga, 2012; Y. Wang et al., 2011), including information about one‘s health status

and concerns about one‘s health. A clear understanding of one‘s health status and

adequate information about the benefits of treatment motivated sex workers to seek

health care (Beattie et al., 2012; Chakrapani et al., 2009). Various health concerns

also facilitated their health-seeking behaviour, such as perceptions of the risk of

becoming infected with HIV/STIs (Surratt et al., 2014; Underhill et al., 2014; Varga,

2012), perceptions of the severity of their symptoms (Marlow et al., 2014; Porras et

al., 2008; Underhill et al., 2014; Varga, 2012), and the belief that maintaining good

health is a matter of commitment to their family (Chakrapani et al., 2009).

Facilitators at the interpersonal level

Nine studies identified social support and peer influence as facilitators at the

interpersonal level that encouraged access to health services (Basnyat, 2017; Beattie

et al., 2012; Chakrapani et al., 2009; Marlow et al., 2014; Ngo et al., 2007; F. M.

Smith & Marshall, 2007; Surratt et al., 2014; Underhill et al., 2014; Y. Wang et al.,

2011). The social network of sex workers served as a source of health information

and support (Basnyat, 2017; Chakrapani et al., 2009; Marlow et al., 2014; Ngo et al.,

2007; Y. Wang et al., 2011), and emotional and practical support from peers

encouraged individuals to seek access to health services (Beattie et al., 2012; Marlow

72
et al., 2014; F. M. Smith & Marshall, 2007; Y. Wang et al., 2011).

Facilitators at the institutional level

Seventeen studies described facilitators at the institutional level (Beattie et al., 2012;

Ghimire et al., 2011; Jeal & Salisbury, 2004; Kimani, 2014; Lafort et al., 2016;

Marlow et al., 2014; Ngo et al., 2007; Nguyen et al., 2008; Phillips & Benoit, 2005;

Rosenheck et al., 2010; Savva, 2013; Scorgie et al., 2013; Shannon et al., 2005;

Surratt et al., 2014; Underhill et al., 2014; Varga, 2012; W.-C. Wong, 2003) as

consisting of high-quality care, services that are available, accessible, and affordable,

and clinics where sex workers did not feel stigmatized.

Facilitators at the institutional level were the most notable factors

encouraging sex workers to utilize health services. Sex workers wished to be treated

with respect, privacy, and empathy by health care providers who were non-

judgmental and had a positive attitude (Beattie et al., 2012; Kimani, 2014; Marlow et

al., 2014; Ngo et al., 2007; Nguyen et al., 2008; Phillips & Benoit, 2005; Savva,

2013; Scorgie et al., 2013; Varga, 2012; W.-C. Wong, 2003). Approximately 63% of

sex workers in the UK suggested that doctors should have appropriate knowledge of

the sex industry and the needs of the sex workers in their community (Jeal &

Salisbury, 2004). Ten studies reported that available, accessible, and affordable

services were welcomed by sex workers (Jeal & Salisbury, 2004; Kimani, 2014;

Lafort et al., 2016; Ngo et al., 2007; Phillips & Benoit, 2005; Rosenheck et al., 2010;

Shannon et al., 2005; Underhill et al., 2014; W.-C. Wong, 2003). They favoured

clinics that offer comprehensive and integrated services, such as the provision of

condoms, insertion of intrauterine devices, termination of pregnancy, care for

incomplete miscarriages/abortions, and psychological counselling (Jeal & Salisbury,

73
2004; Lafort et al., 2016; Phillips & Benoit, 2005; W.-C. Wong, 2003). Furthermore,

sex workers suggested that clinics have convenient opening hours (Jeal & Salisbury,

2004; Lafort et al., 2016; Phillips & Benoit, 2005; Shannon et al., 2005; W.-C. Wong,

2003), a convenient location (Jeal & Salisbury, 2004; Kimani, 2014; Ngo et al., 2007;

Phillips & Benoit, 2005; Shannon et al., 2005; Underhill et al., 2014; Varga, 2012;

W.-C. Wong, 2003), a user-friendly appointment system (Jeal & Salisbury, 2004),

interpretation services (W.-C. Wong, 2003), and affordable price (Kimani, 2014;

Surratt et al., 2014; Varga, 2012; W.-C. Wong, 2003).

Facilitators at the community level

Non-government advocacy groups play a large role in facilitating the health-seeking

behaviour of sex workers (Beattie et al., 2012; Chakrapani et al., 2009; Savva, 2013).

Non-governmental organizations (NGOs) use various strategies to help sex workers

overcome barriers to the use of health services, such as providing information on

antiretroviral therapy (ART), helping to initiate treatment (Chakrapani et al., 2009),

providing emotional support and financial assistance (Beattie et al., 2012), providing

sex workers with knowledge of their legal and human rights (Savva, 2013),

advocating government support for HIV treatment, and working for corruption-free

health services (Beattie et al., 2012).

Facilitators at the policy level

Health care subsidies from the government were cited as an important facilitator at

the policy level that motivated sex workers to access health services in some

developing countries in Asia. Studies conducted in China, India, and Vietnam

reported that given the concern of sex workers about the affordability of health

74
services, a policy of offering free or subsidized health care consultations and

treatments would be a powerful facilitator of the utilization of health services

(Beattie et al., 2012; Ngo et al., 2007; Y. Wang et al., 2011; W.-C. Wong, 2003).

4.5. Discussion

To our knowledge, no previous review of the literature has focused on barriers and

facilitators to the accessing of health services by sex workers. This review shows that

the factors that influence the health-seeking behaviours of sex workers can be

categorized under the socio-ecological model as intrapersonal, interpersonal,

institutional, community, and policy level factors. The results of this review suggest

that barriers at multiple levels need to be addressed, and that facilitators be

maintained or established to improve access to health services by sex workers. The

most prominent barriers and facilitators identified from this review are discussed

below, as well as relevant interventions to increase the uptake of health services by

sex workers.

Reducing stigmatizing attitudes among health professionals towards sex workers

Stigma is the most prominent barrier deterring sex workers from seeking health

services. The findings from this review demonstrated that strong social and

internalized stigma against sex work contributed to sex workers‘ reluctance to seek

appropriate treatment. Social stigmatization of sex work negatively impacted the

provision of health care. The stigma attached to sex work is prevalent in health care

settings. With their negative and stigmatized attitudes and denial of treatment to sex

workers, health professionals neglect their duty to safeguard all patients and promote

health, and violate the sex workers‘ equal rights to health. Meanwhile, the fear of

75
disclosing their occupation to health professionals has limited the ability of sex

workers to access care, which could undermine the accuracy of diagnoses and the

effectiveness of treatments. Their negative experiences with health providers further

affect their future use of formal medical services.

The WHO guidelines on HIV/ STI prevention and treatment for sex workers

(2012) state that, all health services, including primary health care, should be made

―available, accessible and acceptable to sex workers based on the principles of

avoidance of stigma, non-discrimination and the right to health‖ (p.8) (World Health

Organization, 2012). This review highlighted the importance of removing obstacles

faced by sex workers in accessing health services and combating stigma in health

care settings. The ability to deliver appropriate and sensitive services to sex workers

requires that health professionals be equipped with sufficient knowledge of the sex

industry and the health concerns of sex workers. It is critical that health professionals

examine their deeply held values and their perceptions of sex workers, and be aware

of the right of all humans to health. Such awareness would potentially benefit the

health of sex workers.

Also, there is evidence that requiring health professionals to undergo a

sensitivity training programme can improve their knowledge and attitudes towards a

stigmatized population. For example, an-online computer-facilitated MSM

sensitivity programme in Kenya significantly improved health professionals‘

knowledge of the sexual health issues of MSM and reduced their personal

homophobic attitudes (Van der Elst et al., 2013). Therefore, requiring all health

professionals and students in health-related professions to take part in sensitivity

training programmes towards sex workers may have a promising effect on reducing

bias and result in the delivery of non-judgemental and quality health care to all sex

76
workers.

Available, acceptable, affordable, and accessible health services

The findings of this review indicate that there is a lack of available, acceptable,

affordable, and accessible health services for sex workers. Many of the health

services failed to meet the multiple health needs and priorities of the sex workers.

The sex workers would like to see health service offerings expanded beyond the

treatment of HIV and STIs to include the integration of treatments for reproductive

health, mental health, and substance dependence in the same health care settings.

Sex workers suggested various strategies to improve the acceptability of

health services. The presence of health professionals with a friendly and non-

judgemental attitude towards sex workers and sufficient knowledge of the sex

industry and the health needs of sex workers, and assurance of patient confidentiality

would enhance their trust and ensure that the services provided would be more

acceptable to them.

It is also evident that a significant number of sex workers have been shut out

of accessing health services because they are unable to afford the costs. Government

programmes to offer free or subsidized health care to sex workers will improve their

access to health services, and are essential to improving the health of sex workers.

The accessibility of services was also highlighted in this review. Sex workers

considered that to be accessible and responsive to their specific needs, health

services should offer extended service hours, convenient locations, mobile clinic

services, and a user-friendly appointment system. In China, a clinic was launched

according to the preferences of sex workers. The clinic was refurbished, the staff

received further training, and the clinic was opened to the general public to reduce its

77
stigma, while the opening hours were extended to suit the needs of sex workers.

Subsequently, a dramatic increase was seen in the utilization of the clinic among sex

workers (W.-C. Wong, 2003). To meet the health needs of sex workers and to

improve their access to health services, it is critical that their voices be heard in the

planning and implementation of such services.

Informal networks and the role of peer educators

Informal networks were identified as both a facilitator and a barrier to the uptake of

health services by sex workers. Sex workers are more likely to trust their peers and

rely on their informal network to provide them with information on health services.

Since sex workers are hard to reach and highly mobile, it could be a challenge for

health professionals to access and deliver health information and services to them.

Therefore, peer educators could play a fundamental role in reaching sex workers and

improving their access to health care. Results from previous studies on the

effectiveness of peer education programmes for FSWs showed that peer education

interventions significantly increased knowledge of HIV/STIs, reduced STIs, and

increased condom use among FSWs (Ford, Wirawan, Suastina, Reed, & Muliawan,

2000; Morisky, Stein, Chiao, Ksobiech, & Malow, 2006). Thus, health professionals

may achieve the goal of improving the access of sex workers to health by working

closely with peer educators. Training peer educators would potentially influence the

health-seeking behaviours of sex workers and improve their utilization of health

services.

Reducing stigmatizing attitudes in the community

Fostering of a supportive community environment in which sex workers can be

78
comfortable to seek help is important, including efforts to reduce social stigma

against sex workers. Community mobilization interventions have demonstrated to be

successful in reducing social stigma toward sex workers in India (Van der Elst et al.,

2013). It facilitated social acceptance of sex workers through increasing awareness

of sex workers‘ health needs, protecting their human rights, providing health-related

resources, and advocating changes in societal attitudes toward sexuality and sex

work among multiple stakeholders, such as police, policy-makers, brothel owners,

civic and social clubs (I. Basu et al., 2004). The replicability of the intervention

should be tested in future programs and interventions in different countries or legal

systems.

Legal and policy environment

The legal and policy environment contribute to the inequalities in health and health

care utilization among sex workers. The previous review has summarized that sex

workers were more vulnerable to HIV infection, violence, and exploitation in

countries where sex work was illegal (Decker et al., 2015). Challenges also exist

concerning disparities in access to care. Findings from this review further showed

that the prostitution laws that link sex work with criminality drove sex workers

underground and increased their risk of social isolation from health services (Kurtz

et al., 2005). Therefore, to facilitate the use of health services and reduce the health

care disparities faced by sex workers, it calls for respect and protect sex workers‘

basic human rights to health services regardless of the legal status of prostitution.

4.6. Limitations

Although the socio-ecological model addresses the complexities of the health-

79
seeking behaviours of sex workers, and offers strategies to improve their access to

health care, the model also has limitations. It fails to show how factors at each level

influence health behaviours. The complexity of the model also reflects the

practicalities and difficulties of developing appropriate interventions (Stokols, 1996).

In addition, there are several limitations in the present systematic review;

therefore, the findings in this review should be interpreted with caution. First, much

of the evidence was drawn from convenience samples, and the size of the samples

varied considerably from study to study, which could limit the generalizability of the

findings. Second, given the stigmatized nature of sex work and HIV status, this

review cannot be free from the possibility of social desirability bias in the ways that

sex workers described their health-seeking experiences. Third, this review only

included peer-reviewed articles, while the grey literature relating to this topic and

unpublished surveys were not accessible; thus, this review may be susceptible to

publication bias. Lastly, this review only included studies published in English.

Therefore, it is possible that we have missed studies on this topic in non-English

language journals.

4.7. Summary

The utilization of health services by sex workers is a complex issue involving a wide

range of barriers and facilitators at the intrapersonal, interpersonal, institutional,

community, and policy levels. The socio-ecological model provides an approach to

understanding how these multilevel factors affect the health-seeking behaviours of

sex workers. This information could help policymakers, health care providers, and

advocates for sex workers develop acceptable, affordable, and accessible health

services for sex workers. Also, health services or future intervention studies should

80
take into account the facilitators and barriers identified in this review to improve the

health services utilization and health of sex workers, as part of the effort to protect

the right of humans to health.

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 Chapter 5 The conceptualization of stigma
and measurement of attitudes toward sex workers

[Link]

[Link]

5.1.1. Conceptualization of stigma

5.1.2. Levels of stigma and consequences

5.3. The stigma associated with sex work

[Link] for future interventions to reduce the stigma of sex work

82
5.1. Introduction

The review of the literature in the previous three chapters (chapter 2- 4)

demonstrated that stigma towards sex work significantly affect health and the

healthcare seeking behaviours of sex workers. The pervasive stigma and

discrimination against sex workers persist within health care facilities, and is a key

barrier to the access of healthcare by sex workers at multi-levels: intrapersonal,

interpersonal, institutional, community and policy levels.

The reviews of literature conducted clearly pointed to the direction that

research study should focus on the stigma associated with sex work and its impact on

access or provision of healthcare services from the perspectives of different

stakeholders. Before related studies can be conducted, it is necessary to have a clear

conceptualization of the term stigma and the impact of stigma on sex workers.

5.2. Stigma

5.2.1. Conceptualization of stigma

The ancient Greeks word, ―stigma‖ referred to a kind of tattoo that was cut or burned

into the skin of criminals, slaves, or traitors to visibly identify them as blemished or

morally polluted persons (Van Brakel, 2014). The word was later applied to other

personal attributes. According to the classic definition of stigma provided by Erving

Goffman (1963), it is ―an undesirable or discrediting attribute that an individual

possesses, thus reducing that individual‘s status in the eyes of society.‖(p.3) (Erving,

1963).

Erving listed three categories of discrediting attributes that could lead to

social exclusion and rejection of individuals or groups: 1) ―abominations of the

body‖, such physical deformities; 2) ―blemishes of individual character‖, such as

83
drug addiction, mental disorder, problem gambling, imprisonment, homosexual; and

(3) the tribal feature of stigma, such as race, nationality, or religion (Erving, 1963).

Erving‘s work sheds light on the underlying conceptualization of stigma.

Jones and colleagues (1984) defined stigma as a ―mark‖ that sets a person apart from

others and links the marked person to undesirable characteristics (Jones, 1984). They

further conceptualized stigma into six dimensions, namely: concealability (whether

the ailment is visible or hidden); course (how the illness will progress over time);

disruptiveness (whether the condition interferes with daily living and interpersonal

interactions); aesthetic qualities (whether the illness is aesthetically unpleasing);

origin (the cause of the disorder); and peril (whether the disorder will be destructive

to the self or others). Corrigan et al. in 2001 added three dimensions of stigma:

stability (whether the person will get benefit from the treatment); controllability

(whether the behaviour/disorder is controllable); and pity (disorders who are pitied

received less stigma) (Corrigan, River, et al., 2001).

A clear conceptualization of stigma was put forward by Link & Phelan as

‗the co-occurrence of labeling, stereotyping, separation, status loss, and

discrimination in a context in which power is exercised‘ (p.367) (Link & Phelan,

2001). In parallel with Link and Phelan‘s conceptualization of stigma, Corrigan et al.

proposed the social cognitive model of stigma, which focused on the cognitive and

behaviour core features of stigma: stereotype, prejudice, and discrimination

(Corrigan, 2000; Corrigan, Edwards, Green, Diwan, & Penn, 2001). Stereotype is the

cognitive dimension and refers to knowledge structures or negative beliefs about a

large group of people. Prejudice is the cognitive and affective consequence of

stereotype, which refers to the agreement with stereotype beliefs and or negative

emotions, such as anxiety, fear, anger. Discrimination is the consequence of

84
stereotype and prejudice (Corrigan, 2000; Corrigan, Edwards, et al., 2001) (Corrigan

& Watson, 2002; Thornicroft, Rose, Kassam, & Sartorius, 2007).

5.2.2. Levels of stigma and consequences

There are three main levels of stigma: public stigma, self-stigma, and structural

stigma. (Ahmedani, 2011). Public stigma is the attitudes and beliefs that the general

public held toward the stigmatized population and their family members. Self-stigma

occurs when the individuals who belong to a stigmatized group accept and

internalize society‘s negative attitudes (Corrigan & Watson, 2002). Structural stigma

refers to the ways institutions legitimize and perpetuate stigma (Corrigan & Lam,

2007). Health professional stigma is one of the most studied structural stigma

(Ahmedani, 2011; Henderson et al., 2014; Nordt, Rössler, & Lauber, 2006; Nyblade

et al., 2019), since health professionals‘ personal values may shape their attitudes

toward the patients (Dorsen & Van Devanter, 2016; Ferri, Guerra, Marcheselli,

Cunico, & Di Lorenzo, 2015).

The consequences of stigma could be devastating. Mounting evidence

suggests that stigma is the fundamental cause of social inequity (Hatzenbuehler et al.,

2013). Public stigma and health professional stigma may lead to various

discriminative behaviours, such as gossip (Frey, Hans, & Cerel, 2015), verbal

harassment (Hughto, Reisner, & Pachankis, 2015), violence (Hughto et al., 2015),

sexual assault (Hughto et al., 2015), social isolation (Rao, Angell, Lam, & Corrigan,

2008), rejection, unemployment (Rao et al., 2008; Stergiou-Kita, Pritlove, & Kirsh,

2016), breach of confidentiality and privacy (Beattie et al., 2012; Rahmati-

Najarkolaei et al., 2010), and other human rights violations (Zalat, Mortada, & El

Seifi, 2018). Individuals who accept societal stigma as legitimate may suffer from

85
diminished self-esteem and self-efficacy (Corrigan, Watson, & Barr, 2006), lowered

quality of life (Corrigan & Watson, 2002), increased chance of mental disorders, and

even suicide attempts (Corrigan et al., 2006), and delayed or refusal of treatment

(Katz et al., 2013).

5.3. The stigma associated with sex work

There is a strong stigmatizing attitude towards sex workers throughout history.

Pervasive stigma and discrimination threaten the health and wellbeing of sex

workers. It may compromise their ability to negotiate the use of condoms to protect

themselves from human immunodeficiency virus (HIV) infection and other sexually

transmitted diseases (STDs) (Choi & Holroyd, 2007). Stigma could also impact the

mental health of sex workers (Y. Hong et al., 2010), contributing to the use of illegal

drugs (Bletzer, 2005; Dodsworth, 2014; McClelland & Newell, 2008). The stigma

associated with sex work could be further complicated with the added stigma

associated with HIV or STDs, drug addiction, homelessness, and mental disorders

(Gu et al., 2014; Kurtz et al., 2005; Mtetwa et al., 2013). This multi-layered stigma

could adversely affect sex workers‘ behaviours, physical and psychological health,

and health-seeking behaviours (Donastorg, Barrington, Perez, & Kerrigan, 2014; Gu

et al., 2014).

5.4 Recommendation for future interventions to reduce the stigma of sex work

Stigma is the fundamental determinate of inequalities in the health and health care

services of sex workers. Interventions are suggested to target three primary levels of

stigma to remove the barriers to accessing health care service among sex workers:

public stigma, self-stigma, and structural stigma. One approach would be to change

86
the negative attitudes of health care providers toward sex workers. However, there is

scant literature on the stigma-reduction interventions related to sex work for

professionals and students in health-related disciplines. To shed light on the

development of a stigma-reduction intervention for professionals and students in

health-related disciplines, in the following chapter, a review of the stigma-reduction

intervention among professionals and students in health-related disciplines was

conducted.

87
 Chapter 6 Review of literature (IV)

HIV/AIDS related stigma-reduction intervention for professionals and students

in health-related disciplines – implications for stigma-reduction interventions

related to sex work

[Link] of the review

[Link] of the review

6.3.A search for studies on interventions to reduce the stigmatizing attitudes of health

professionals towards sex work

[Link] stigma-reduction intervention programmes: implications for strategies for

interventions to reduce the stigma related to sex work

[Link]

6.5.1. Search of the literature

6.5.2. Inclusion and exclusion criteria

6.5.3. Appraisal of the quality of the included studies

6.5.4. Data extraction and synthesis

[Link]

6.6.1. Characteristics of intervention studies

6.6.2. Characteristics of the interventions

6.6.3. Outcome-measuring instruments

6.6.4. Outcomes of the interventions

[Link]

[Link] of the study

[Link]

*Content of this chapter is submitted:

88
Ma, P. H., & Loke, A. Y. (2019d). A scoping review of an HIV/AIDS-related stigma-

reduction intervention for professionals and students from health-related

disciplines – Implications for stigma-reduction interventions related to sex work.

(International Journal of Sexual Health, major revision)

89
6.1. Background of the review

Findings from previous chapters indicate that sex workers face significant barriers to

accessing health services (Chapter 4). The negative attitudes of healthcare providers

toward sex workers has been recognized as a critical factor that influences service

provision and disparities in health (Chapter 3 and 4). Studies have suggested that

knowledge about the sex industry and non-judgmental attitudes on the part of

healthcare providers towards sex workers would enhance the trust towards them felt

by the sex workers and subsequently improve the latter‘s access to health care

(Phrasisombath et al., 2012). Therefore, reducing sex work-related stigma among

healthcare providers, including nursing professionals, is critical to addressing health

disparities between sex workers and the general population.

6.2. Aim of the review

The aim of this review was to find out the existing intervention to reduce the stigma

of health professionals towards sex workers.

6.3. A search for studies on interventions to reduce the stigmatizing attitudes of

health professionals towards sex work

Search strategies and the Process of Selecting Studies

The following eleven databases were searched for studies listed from their inception

to November 2017: Medline, Embase, Cochrane Library, PsychINFO, CINAHL,

Web of Science, Scopus, Social Services Abstracts, PubMed, British Nursing Index,

and ProQuest Dissertations and Theses. The search terms included medical subject

headings (MeSH) terms and key words for ―sex worker‖ and terms associated with

―attitude‖, ―healthcare providers‖, and ―intervention‖: (1) sex worker (―sex work*‖

90
or ―prostitute*‖ or ―sex industry‖); (2) stigma (―stigma or ―social stigma‖ or ―stigma

reduction‖ or ―anti-stigma‖ or ―attitude‖ or ―discrimination‖ or ―anti-discrimination‖

or ―social isolation‖ or ―social distance‖ or ―prejudice‖ or ―shame‖ or ―tolerance‖ or

―empathy‖); (3) health professionals (―healthcare worker‖ or ―health professional‖ or

―health personnel‖ or ―healthcare provider‖ or ―nurs*‖ or ―doctor‖ or ―medical

student‖ or ―physician‖ or ―dental‖ or ―health setting‖); (4) intervention

(―intervention or program‖ or ―education‖ or ―training‖ or ―trial‖ or ―workshop‖). A

manual search of the references of the identified literature and an author search were

also conducted.

Inclusion and Exclusion Criteria

Studies were included in this review if they fulfilled the following criteria: (1) the

study focused on healthcare providers or students from health-related disciplines; (2)

the intervention included a component on the reduction of stigmatizing attitudes by

healthcare providers towards sex workers; (3) the study was either experimental or

quasi-experimental in design; (4) the study was published in English. Studies were

excluded if the intervention focused on reducing stigma toward those with other

stigmatized conditions (e.g., people with human immunodeficiency virus (HIV),

mental illness, drug users, etc.). Conference abstracts, review articles, and studies

published in languages other than English were also excluded. Figure 6-1 contains a

flow diagram of the search and selection process.

A total of 3,198 studies were identified, 296 duplicates were culled, and

2,897 were removed when abstracts were screened based on the exclusion criteria.

The full text of the five studies that remained were examined, and only two met the

inclusion criteria.

91
 Records identified through Additional records identified through
Identification

database searching hand search

(n =3198) (n =0)

Records after duplicates removed

(n =2902)
Screening

Records screened Records excluded based on

(n =2902) exclusion criteria (n=2897)
Eligibility

Full-text articles excluded, with

Full-text articles assessed for reasons (n =3)
eligibility 1. Intervention for sexual
(n =5) minority (gay, lesbian,
bisexual) (n=1)
2. Description study (n=1)
3. Cross-sectional survey
(n=1)
Included

Studies included in the review

(n =2)

Figure 6-1 The flow diagram on identifying the literature

92
Sex work-related stigma-reduction intervention programmes

Only two intervention studies were identified in the search for relevant literature.

One was a programme carried out by a medical student and a female sex worker

(Robitz, Morrison, Ventura, Melton, & Bennett, 2015), and the other was a stigma-

reduction intervention conducted by a family planning and reproductive health

service in partnership with an International HIV/AIDS Alliance group (Geibel et al.,

2017).

The programme headed by the medical student and sex worker was to teach

medical students about the physical and mental health of sex workers (Robitz et al.,

2015). The programme consisted of 10-weekly sessions of 1.5 hours each. In two

sessions, sex workers and medical students were given opportunities to discuss

specific topics raised by the participants, such as the personal stories of sex workers

and what students had learned about how to be a physician sensitive to the health

needs of sex workers. Although there were no formal evaluations, the feedback was

obtained from both the sex workers and the medical students who participated in the

programme. The sex workers who participated were empowered to take control of

their health and their lives, while the medical students valued the programme as an

experience that gave them a better understanding of sex workers, and would enable

them to be more sensitive in delivering health services in their future practice.

Another programme for healthcare providers was conducted by ―Marie

Stopes Bangladesh‖ (a family planning and reproductive health service) in

partnership with ―Link Up‖, an International HIV/AIDS Alliance group in

Bangladesh (Geibel et al., 2017). The aim of the programme was to reduce the

stigma felt by health professionals towards marginalized populations, including sex

workers, those with HIV, and men who have sex with men (MSM), transgender

93
people, as well as sexually active young people and single pregnant girls. It was a

two-day programme, which included a day spent providing information on

reproductive health and HIV services, health rights, the risk of HIV transmission,

and related stigma. Another day was devoted to highlighting the influence of social

stigma and personal values towards these marginalized populations, and to

promoting stigma-free services in health services.

Assessments were made of the attitudes of the health providers and the

clients‘ satisfaction with the services that they provided. The former were assessed at

baseline, and 6 and 12 months after the intervention, while the latter were assessed at

baseline and 12 months. The attitudes of health providers toward sex workers

improved significantly. There was reduced the negative attitude towards sex workers

as people ―engaging in immoral behaviours‖ (51.0% - 25.3%, p < 0.001). The fear of

acquiring HIV from sex workers was reduced from 19.7% to 7.0% (p = 0.001). The

percentage of those who were unwilling to provide services to sex workers was

reduced from 5.3% to 1.0% (p = 0.035). At 12 months after the programme, sex

workers expressed overall satisfaction with the health services provided at the center

and reported a substantial decrease in enacted stigma (10.7% - 0.0%, p < 0.01).

A paucity of intervention studies on stigma related to sex work

There are several possible reasons for the lack of intervention studies on stigma

related to sex work. First, healthcare providers might have failed to recognize or

might have under-emphasized the association between their attitude of stigmatization

and the access to health services and the health outcomes of sex workers (Lau, Choi,

Tsui, & Su, 2007). Second, discussions on the health disadvantages of sex workers

have focused on the link to sexually transmitted diseases (STDs)/HIV, and related

94
stigma-reduction interventions for healthcare providers have focused on people

living with HIV/AIDS and not specifically on sex workers. Third, with the

criminalization of prostitution being the dominant policy in most countries, sex work

is a complex and sensitive topic in many parts of the world (The Joint United

Nations Programme on HIV/AIDS, 2010). In places where it has been criminalized,

sex work is viewed as an immoral profession. The stigma associated with sex work

is considered a social and legal issue, and there is a misconception that attitudes

toward sex workers will be difficult to change.

6.4. HIV stigma-reduction intervention programmes: implications for strategies

for interventions to reduce the stigma related to sex work

The stigmatizing attitude of the public towards sex workers can be compared with

that towards people with HIV. The HIV/STD status of sex workers was found to

have a major influence on the attitudes and behaviours of nurses towards sex

workers (Ma & Loke, 2019a, 2019b). Given the paucity of interventions focusing on

reducing the stigma of health professionals towards sex workers, it is postulated that

stigma-reduction interventions related to HIV/AIDS could be used as a reference to

develop stigma-reduction interventions for health professionals with regard to sex

work.

Several reviews have been written on interventions to reduce HIV/AIDS-

related stigma among various stakeholders, including healthcare professionals,

students in health disciplines, PLWHA, caregivers of HIV/AIDS patients,

populations at risk, and the general public (Brown, Macintyre, & Trujillo, 2003; Mak,

Mo, Ma, & Lam, 2017; Sengupta, Banks, Jonas, Miles, & Smith, 2011). The

following literature review identifies the contents, the approaches that were adopted,

95
and the outcome measures of existing interventions to reduce stigma related to HIV,

to achieve a better understanding of stigma-reduction interventions focusing

specifically on health professionals and students from health-related disciplines.

6.5. Methods

6.5.1. Search of the literature

A search for relevant literature contained in the following electronic databases was

conducted from the inception of these databases to April 2018: Medline, Embase,

Cochrane Library, PsychINFO, CINAHL, Web of Science, Scopus, Social Services

Abstracts, PubMed, British Nursing Index, and ProQuest Dissertations and Theses.

The keywords used to interrogate these databases were: 1) HIV/AIDS or HIV/AIDS

risk group population (―HIV‖ or ―Acquired Immunodeficiency Syndrome‖ or ―AIDS‖

or ―people living with HIV AIDS‖ or ―PLWHA‖ or ―Sexually Transmitted Infection‖

or ―Sexually Transmitted Diseases‖ or ―Homosexuality, Female or Bisexuality‖ or

―Homosexuality‖ or ―Homosexuality, Male‖ or ―Transgender Persons‖ or ―lesbian‖

or ―gay‖ or transgender‖ or ―sex worker‖ or ― prostitution‖ or ―substance abuse‖ or

―drug abuse‖); 2) stigma reduction (―stigma reduc*‖ or ―anti-stigma‖ or ―attitude

change‖ or ―social distance‖ or ―social isolation‖ or ―anti-discrimination‖ or

―discrimination reduc‖); 3) health care providers (―health care worker‖ or ―health

professional‖ or ―health personnel‖ or ―health care provider‖ or ―nurs*‖ or ―doctor‖

or ―health setting‖); 4) intervention (―intervention‖ or ―program‖ or ―evidence-based‖

or ―health education‖ or ―train*‖).

6.5.2. Inclusion and exclusion criteria

The criteria for studies to be included in this review were those that: (1) were written

96
in English; (2) aimed at evaluating a stigma-reduction intervention among healthcare

providers/students in health disciplines; (3) focused on stigma associated with

populations living with HIV/AIDS, (4) had at least one outcome measure of

knowledge related to HIV/AIDS stigma, or attitudes or behaviour toward PLWHA;

and (5) were full-text articles. Studies were excluded if they were: (1) not about

HIV/AIDS-related stigma, (2) not focused on healthcare providers or students from

health-related disciplines; (3) conference abstracts, qualitative studies, or literature

reviews; and (4) written in a language other than English.

A total of 3,350 publications were identified from the electronic databases.

Of these, 663 publications were removed due to duplication, and the remaining 2,687

abstracts were screened. Of these, 2,637 publications were excluded. The full texts of

the remaining 50 articles were examined in detail, and a further 10 studies were

excluded. Five additional relevant studies were retrieved from a manual search of the

reference lists of the included studies. Finally, a total of 45 studies were included in

this review. A flowchart of the literature search and selection process is given in

Figure 6-2.

97
 Records identified through Additional records identified

Identification
database searching through hand search
(n =3350) (n =5)

Records after duplicates removed

(n =2687)
Screening

Records screened Records excluded based on

(n =2687) exclusion criteria (n=2637)
Eligibility

Full-text articles excluded,

Full-text articles assessed for with reasons (n =10)
eligibility 4. Descriptive study
(n =50) (n=8)
5. Duplicate studies
(n=2)
Included

Studies included in the review

(n =45)

Figure 6-2 The flow diagram on identifying the literature

98
6.5.3. Appraisal of the quality of the included studies

The Downs and Black Quality Index was used to evaluate the methodological quality

of both randomized controlled trials and quasi-experimental trials. The index

consists of 27 questions relating to the quality of the reporting (10 items), the

external validity (3 items), internal validity (bias and confounding) (13 items), and

statistical power (1 item) (Downs & Black, 1998). The maximum score of the

checklist is 28. Each paper was assigned a grade of ―excellent‖ (24–28 points),

―good‖ (19–23 points), ―fair‖ (14–18 points), or ―poor‖ (<14 points) (O‘Connor et

al., 2015).

Overall, the 45 studies were considered to be of low to moderate quality, with

the index scores ranging from 8 to 19 (Downs & Black, 1998). Twenty-five studies

were rated as poor, 19 as fair, and only one as good.

It may be argued that the approach of including all studies regardless of

methodological quality might lower confidence in the results. However, given that

the aim of this review was to identify the types, approaches, formats, and contents to

be included in interventions, limiting the studies to be included might have reduced

the generalizability of the identified features of the relevant interventions (Lam &

Kennedy, 2005). Thus, the decision was made that no study would be excluded based

on the outcome of the quality appraisal.

The approach of a scoping review was therefore adopted to include studies

broadly about the topic, so as to provide more comprehensive evidence when

identifying the key features of related intervention studies that differed from a

common literature review (Arksey & O'Malley, 2005; Peters et al., 2015). Details of

the appraisal of the quality of these studies are given in Appendices Table 6-1.

99
[Link] extraction and synthesis

The characteristics of the studies and key findings were extracted and tabulated

according to the author(s), year of publication, the country where the research was

conducted, study design, settings, participants, intervention type and contents,

theoretical framework, the dosage of the intervention, facilitators, measurements,

and key findings. The characteristics and key results of these studies are summarized

and categorized in Appendices Table 6-2 and Appendices Table 6-3, respectively. A

meta-analysis was not performed due to the heterogeneity of the various

measurements used to measure outcomes in the included studies.

The sample size, mean, and standard deviation were extracted or calculated

for each study at the pre-test, post-test, and the last follow-up time points. The effect

size was extracted where the data were available in the studies, or calculated where

unavailable. The effect size of an individual RCT study was calculated by the

difference between two mean values and the pooled standard deviation. The effect

size for a quasi-experimental study with control groups was calculated by subtracting

the mean change score in a control group from the mean change score in an

intervention group, divided by the pooled standard deviation of the pre-test score

(Morris, 2008). The effect size was defined as small (d=|0.2|, η2≈1%), medium

(d=|0.5|, η2≈10%), and large (e.g. d=|0.8|, η2=25%), respectively (Cohen, 1988). A

bias correction component was used to correct for bias when the sample size was

smaller than 10 (Morris, 2008). The effect sizes of one group pre-post interventions

were not calculated. Also, the effect sizes were not presented for studies without

sufficient data (See Appendix XIII).

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6.6. Results

6.6.1. Characteristics of intervention studies

Of the 45 included studies, 12 were randomized controlled trials (RCTs,) 14 were

quasi-experimental studies with a control group, and 19 were quasi-experimental

studies without a control group. Most were conducted in Asia (n=19), followed by

Africa (n=7), North America (n=14), Europe (n=4), and Australia (n=1). The size of

the sample in the studies varied markedly from 29 to 1,760.

Target population

The majority of the studies focused on HIV-related stigma reduction among

healthcare providers (n=27), including physicians, nurses, mental health

professionals, dentists, physical therapists, occupational therapists, anaesthesiologists,

primary care clinic health providers, lab technicians, and other support staff.

Seventeen interventions concentrated on students from health-related disciplines,

including students from medicine, nursing, counselling, pharmacy, and physical

therapy. One study targeted both medical professionals and medical students.

Nursing students (n=9) and practising nurses (n=10) were the most studied groups.

Details of the characteristics of the participants are summarized in Appendices Table

6-2.

The theoretical framework of the interventions

Various theoretical frameworks were adopted in these studies to guide the design of

the interventions. The theories that were adopted included both cognitive and

behavioural elements: the social cognitive theory (n=3), the social learning theory

(n=1), the social cognitive learning model (n=1), the theory of planned behaviour

101
(n=1), the diffusion of innovation theory (n=1), and Watson‘s theory of human

caring (n=1). Three studies adopted primary health frameworks, namely Green and

Kreuter‘s PRECEDE/PROCEED model (n=1), the World Health Organization‘s

primary health-care model (n=1), and Bloom‘s Taxonomy conceptual framework

(n=1). Three interventions adopted the training of trainers approach, one study

employed a workshop-practice model, one study applied the popular opinion leader

model, and one study adopted a self-developed conceptual framework on HIV

stigma.

6.6.2. Characteristics of the interventions

Approaches and content

The characteristics of the interventions are presented in Appendices Table 6-3. The

interventions consisted of a single approach or a combination of approaches,

including an information-based approach, approaches that involved the provision of

biomedical knowledge, the building of skills, counselling/support, contact with and

sharing by affected groups, and structural approaches. Below is a description of the

approaches, presented in order of their popularity of use in interventions.

Information-based approach

The information-based approach was most popular and was adopted in 44 of the 45

included studies. Fifteen studies adopted that approach alone, and the other studies

did so in combination with other approaches. An information-based approach

included the provision of information on HIV/AIDS, disease prevention, universal

precautions, treatment, sexual and reproductive health, the human rights of PLWHA,

professional ethics, confidentiality and privacy, discussion of issues related to gender,

102
stigmatization, discrimination, stigma-reduction strategies, and community resources

(Brown et al., 2003; Stangl, Lloyd, Brady, Holland, & Baral, 2013). Information was

delivered through a brochure, a video, a classroom presentation, advertisements, peer

education, or guided group discussions. Of the 15 studies that adopted this as the

only approach, 11 observed a significant improvement in the participants‘

knowledge and attitudes toward PLWHA.

Contact with and sharing by the affected group

The second most popular approach, which was adopted in 21 studies, was to offer

participants the opportunity to come into contact with the affected marginalized

groups (PLWHA) and share thoughts with them. The interaction between the

affected groups and healthcare providers/students in health disciplines occurred

either directly or by recorded testimonial. The PLWHA would share their feelings

and experiences of being a patient with HIV. Healthcare providers also had the

opportunity to interact and communicate with PLWHA (Brown et al., 2003; Stangl et

al., 2013). Only one study adopted this approach solely, offering a three-hour

patient-centred education programme of direct contact with the affected groups. The

study demonstrated a statistically significant improvement in the attitudes of students

in health-related disciplines toward caring for PLWHA (Chisholm, Ricci, & Taylor,

1999).

Skills building

The third most popular approach adopted in 16 out of 45 studies was the skill-

building approach. This refers to the learning of strategies to resolve negative

attitudes, coping strategies, and hands-on skills, including skills in communicating

103
with PLWHA (Brown et al., 2003; Stangl et al., 2013). This approach was delivered

through role-play, master imagery, reframing and relaxing techniques, group

desensitization, and scripting. None of the studies utilized this approach solely in

their intervention.

Counselling approach

A counselling approach was adopted in eight studies in combination with other

approaches. This approach involved providing support for positive behaviours, such

as one-to-one counselling and support groups (Brown et al., 2003; Stangl et al.,

2013).

Biomedical approach

The biomedical approach refers to interventions such as taking universal precaution

in the provision of care and treatment (Stangl et al., 2013). This strategy was adopted

in two studies.

Structural approach

The structural approach refers to interventions that reduce stigma by altering the

social and structural determinants of HIV/AIDS-related stigma, such as socio-

ecological models involving multiple levels, including the individual, interpersonal,

organizational, community, and policy levels (Stangl et al., 2013). Two multi-level

interventions targeted both the individual level and the organizational level and

established a hospital steering committee and hospital guidelines for reducing

HIV/AIDS-related stigma.

104
 In summary, a total of 16 studies adopted a single approach, and 29 took a

multi-component approach to reduce HIV-related stigma among healthcare providers.

The information giving, skills building, and contact with and sharing by PLWHA

approaches were the most frequently adopted strategies in multi-component

interventions. Nine studies combined the information giving and contact with

PLWHA approaches, five studies combined the information giving and skills

building approaches, and seven studies combined the three most commonly adopted

approaches. One study employed four approaches, and two adopted all six

approaches.

Delivery

The majority of the interventions were delivered by HIV experts, public health

officers, trained healthcare workers, staff members from non-governmental

organizations, and PLWHA. The majority of the interventions were delivered face-

to-face in healthcare settings or in medical/nursing colleges.

The dosage of the interventions and follow-up time frames

The frequency, duration, and follow-up time of the interventions in these studies

varied widely. The interventions ranged from one to 10 sessions, with the shortest

being a single lecture of 50-minutes duration, and the longest a weekly review of an

HIV case and a didactic discussion among medical residents over six months of

practice. The period of the follow-up also varied from immediately after the

intervention up to 46 months after the completion of the intervention. Among these

interventions, 17 assessed the efficacy of the intervention immediately after the

intervention (See Appendices Table 11-3).

105
6.6.3. Outcome-measuring instruments

Stigma refers to negative stereotypes, prejudicial attitudes, and discriminatory

behaviours directed towards a subject (Corrigan & Watson, 2002; Oskamp & Schultz,

2005; Thornicroft et al., 2007). The instruments to measure stigma that were used in

these studies included those on knowledge, attitudes, and behaviours related to

stigma (Breckler, 1984; Eagly & Chaiken, 1998; Ostrom, 1969).

Measurements of HIV/AIDS-related knowledge

In the studies that were included, standardized measurements for assessing

HIV/AIDS-related knowledge were lacking. Researchers in two-thirds of the studies

(n=24) developed their own knowledge scale by compiling/selecting items from

other studies and reporting on the reliability and validity of their scale, while in the

other 13 studies, the validity and reliability of the scales that were used were not

reported. One study used a single item to rate the participants‘ knowledge of

infectious diseases, nine studies used 4-10 items, eight used 11-20 items, and 14 used

23-198 items, but six studies did not provide information on the number of items

used to assess such knowledge. The majority of the studies assessed factual

knowledge using multiple-choice items. The content of most knowledge items

covered factual information on HIV transmission and prevention, care and treatment,

universal precautions, knowledge of human rights, and informed consent.

Measurements of attitudes towards PLWHA

The measures of the attitudes toward PLWHA also varied considerably across the

studies. A total of 40 studies assessed general attitudes/prejudices/beliefs or stigma

toward PLWHA. The majority of the studies (70%, n=28) adopted validated

106
measurements from other studies, and 12 studies used self-developed measurements

without validation. One study measured attitude with a single item, nine studies with

4-10 items, 12 with 12-20 items, and 12 with over 20 items, while the remaining

studies did not provide information about the number of attitude items (n=6).

The content of these measurements included various domains of attitude,

including emotions toward PLWHA (such as a fear of the transmission of disease,

avoidance, blaming or judgement, sympathy, or empathy), the patients‘ human rights,

the imposition of measures/restrictions on the patients‘ rights, self-efficacy, comfort

level in caring for patients, the rights and responsibilities of health professionals, and

their attitudes toward specific categories of HIV/AIDS patients. The majority of the

studies used Likert-scale measurements.

Measurements of behaviours towards PLWHA

A total of 22 studies measured the behaviours of healthcare workers toward PLWHA.

However, there was also a lack of standardized measurements of behaviour.

Approximately half (n=13) of the measurements were adopted or modified from

previous studies and validated. Three studies used a single item to assess the

participants‘ willingness to care for PLWHA or the practice of standard

precautionary measures when deciding whether or not to provide such care. Ten

studies used 2-5 items, five studies used 8 or more items, and three studies did not

provide information about the number of items that were used to assess the

willingness to provide care for PLWHA.

The content of the measurements of behaviour included a

willingness/reluctance to care for PLWHA, acts of discrimination or the intention to

107
discriminate, and HIV/AIDS-related infection control behaviour. The majority of the

studies used a Likert-scale to assess the behaviour of the participants.

6.6.4. Outcomes of the interventions

The primary outcomes of these interventions were stigma-related knowledge,

attitudes, and behaviours.

HIV/AIDS-related knowledge

A total of 37 studies measured HIV/AIDS-related knowledge as outcomes. The

majority of the studies (n=31/37) reported a significant improvement in HIV/AIDS-

related knowledge. Two studies with multiple approaches achieved a long-term

improvement in HIV/AIDS-related knowledge at the 12 and 46 months follow-up

session (Britton, Rak, Cimini, & Shepherd, 1999; S. Wu et al., 2008). One study

reported some improvement, but it was without statistical significance (Balogun,

Kaplan, & Miller, 1998). Two quasi-experimental studies that employed a single

approach (information or contact) found no statistically significant improvement in

the HIV/AIDS-related knowledge of the participants (Mockiene et al., 2011;

Orlander, Samet, Kazis, Freedberg, & Libman, 1994).

The effect size for HIV/AIDS-related knowledge was extracted or calculated

from 12 studies (Appendices Table 6-4) (Arora, Jyoti, & Chakravarty, 2014;

Balogun et al., 1998; Collins, Mestry, Wainberg, Nzama, & Lindegger, 2006; Diesel

& Taliaferro, 2013; Held, 1993; Mak, Cheng, Law, Cheng, & Chan, 2015; Mockiene

et al., 2011; Nanayakkara & Choi, 2016; Operario et al., 2016; Shah, 2014;

Stiernborg, 1996; Yiu, 2010), including one pre-post study (Collins et al., 2006) (See

Appendices Table 6-4). The short-term effect size ranged from small to large

108
(d=0.06-2.89). One RCT study achieved a large effect size with a 5-day information

only approach (d=0.86), and seven studies that combined information with skills

building and/or contact strategies achieved a large effect size immediately after the

intervention (Collins et al., 2006; Held, 1993; Mak et al., 2015; Mockiene et al.,

2011; Nanayakkara & Choi, 2016; Shah, 2014; Stiernborg, 1996). The above

interventions lasted from 100 minutes to 13 hours.

One RCT study combined information giving, skills building, and contact

strategies in an intervention programme that consisted of one week of group training

and two months of clinical practice. Two sections of the study focused on

presentations, case studies, a group discussion on problem-solving and feedback.

The study reported a large effect size (d=38.8) at the 9-month follow-up session

(Operario et al., 2016).

Attitudes towards caring for PLWHA

The assessments of the attitudes toward PLWAH measured the general attitude

towards PLWHA, the affective attitude towards caring, and self-efficacy and the

perception of the level of skills required to provide such care.

The general attitude towards PLWHA

A total of 40 studies assessed general attitudes toward PLWHA. The majority of

them (n=28) measured attitudes toward AIDS or PLWHA, 11 measured HIV/AIDS-

related stigma or prejudice, and one study assessed attitudes toward HIV/AIDS. In a

total of 31 studies, a significant improvement was observed in attitudes toward

PLWHA. In five studies a long-term effect was observed at the 12-month follow-up

session (Ezedinachi et al., 2002; Geibel et al., 2017; Li et al., 2010; Varas-Díaz et al.,

109
2012; Z. Wu et al., 2002). Among the five studies, three adopted a training the

trainer model (Ezedinachi et al., 2002; Geibel et al., 2017; Z. Wu et al., 2002), and

another two were guided by social and behavioural theories (Li et al., 2010; Varas-

Díaz et al., 2012). Two studies did not report statistical results (Balogun et al., 1998;

Lewis, Gallagher, & Gelbier, 1996). Seven studies reported improved attitudes, but

these did not reach the level of significance (Diesel & Taliaferro, 2013; Gutierrez,

2014; Kemppamen, Dubbert, & Williams, 1996; Mockiene et al., 2011; Orlander et

al., 1994; Shah, 2014; Uys et al., 2009).

The effect size for attitudes toward PLWHA were extracted or calculated

from 13 studies (Arora et al., 2014; Balogun et al., 1998; Collins et al., 2006; Diesel

& Taliaferro, 2013; Held, 1993; Mak et al., 2015; Mockiene et al., 2011;

Nanayakkara & Choi, 2016; Pulerwitz, Oanh, Akinwolemiwa, Ashburn, & Nyblade,

2015; Stiernborg, 1996; Uys et al., 2009; Varas-Díaz et al., 2012; Yiu, 2010),

including one pre-post study (Collins et al., 2006). As shown in Appendices Table 6-

5, the short-term effect sizes ranged from small to large (d=0.02-19.98). One RCT

guided by the social cognitive theory reported a small long-term effect size at the

one-year follow-up session (d=0.30) (Varas-Díaz et al., 2012).

Affective attitude towards caring

A total of 14 studies assessed the affective attitude towards caring for PLWHA. Nine

studies measured the fear, worry, anxiety, blame, or mood-related to care. Six

reported a significant improvement in the fear or mood-related to caring for PLWHA

(Mak et al., 2015; Pisal et al., 2007; Pulerwitz et al., 2015; Varas-Díaz et al., 2012;

Yiu, 2010; Young, Koch, & Preston, 1989). One study, which involved the simple

giving of information, reported reduced anxiety levels but without statistical

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significance (All & Sullivan, 1997). Two studies combining the giving of

information and contact with PLWHA did not achieve a statistically significant

improvement in fear of contagion among the participants (McCann & Sharkey, 1998;

Shah, 2014).

Five studies measured the comfort level in caring for PLWHA. Four studies

with two or three approaches (information, counselling, in combination with skills

building or contact with PLWHA) achieved a significant improvement in the level of

comfort in caring for PLWHA after the intervention (Bluespruce et al., 2001; Britton

et al., 1999; Collins et al., 2006; Stewart, DiClemente, & Ross, 1999). The effect of

two studies was maintained at the 7-month and 46-month follow-up sessions,

respectively (Bluespruce et al., 2001; Britton et al., 1999). However, one study with

three 1-hour sessions that combined the information, skills building, and contact

approaches failed to achieve a significant improvement in the level of comfort in

caring for PLWHA (Kemppamen et al., 1996).

Self-efficacy and perceived skills for caring

Eight studies measured the participants‘ self-efficacy and perceived skills in caring

for PLWHA (Bluespruce et al., 2001; Britton et al., 1999; Kamiru, Ross,

Bartholomew, McCurdy, & Kline, 2009; Kemppamen et al., 1996; Orlander et al.,

1994; Uys et al., 2009; Varas-Díaz et al., 2012; D. Wang, Operario, Hong, Zhang, &

Coates, 2009). In five studies that measured the participants‘ self-efficacy in caring

(Bluespruce et al., 2001; Kamiru et al., 2009; Kemppamen et al., 1996; Orlander et

al., 1994; Varas-Díaz et al., 2012), and in two studies that measured their level of

skills in caring for PLWHA (Britton et al., 1999; D. Wang et al., 2009) significant

improvements were reported in self-efficacy and skills after the intervention.

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However, one study of nurses did not find improvements in self-efficacy in caring

(Uys et al., 2009).

Behaviour towards PLWHA

Among 22 studies that measured changes in behaviour towards PLWHA, 14

measured the participants‘ willingness/reluctance to care for PLWHA. Of these, a

significant improvement in the willingness to care was reported in 10 studies. In two

studies, the effect was maintained at the 12-month and 46-month follow-up sessions,

respectively (Britton et al., 1999; Li et al., 2010). However, in three experimental

studies (one RCT, two quasi-experimental studies) a statistically significant

improvement was not achieved in the willingness of the participants in the

intervention to care for PLWHA (Balogun et al., 1998; Kemppamen et al., 1996;

Orlander et al., 1994) (Appendices Table 6-3).

The effect size of the willingness to care for PLWHA was extracted or

calculated from six studies (Balogun et al., 1998; Diesel & Taliaferro, 2013; Held,

1993; Mak et al., 2015; Shah, 2014; Yiu, 2010) (See Appendices Table 6-6). The

short-term effect sizes ranged from small to large (d=0.16 to 0.58, η2=51.6-53.5%).

One RCT study found that a large effect size in the willingness to care for PLWHA

was achieved in both arms of the intervention (an informative lecture plus an

interactive game with PLHWA, and an educational lecture plus a 90-minute

interpersonal sharing session lead by PLWHA) and that the effect maintained at the

one-month follow-up session (Mak et al., 2015).

Acts of discrimination by the participants or their intention to discriminate

were measured in four studies (Gutierrez, 2014; Mak et al., 2015; Pulerwitz et al.,

2015; Shah, 2014). Three studies with multiple approaches achieved a significant

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reduction in discriminatory behaviour on the part of the participants toward PLWHA

after the interventions (Mak et al., 2015; Pulerwitz et al., 2015; Shah, 2014), while

one study that employed an information-only approach failed to achieve a

statistically significant reduction in discriminatory behaviour (Gutierrez, 2014).

HIV/AIDS-related infection control practices were assessed in five studies

(Charuluxananan, Migasena, Somboonviboon, Chinachot, & Kunthollaxami, 2000;

Lueveswanij, Nittayananta, & Robison, 2000; Stewart et al., 1999; Uwakwe, 2000; S.

Wu et al., 2008). Three studies that combined information and skills building

strategies with a contact or counselling skills approach achieved a significant result

in HIV/AIDS-related control behaviours (Lueveswanij et al., 2000; Stewart et al.,

1999; S. Wu et al., 2008), as did another study featuring a seven-week training

intervention (Uwakwe, 2000). However, another two-day intervention using an

information only approach did not achieve a statistically significant improvement in

HIV/AIDS-related control behaviours (Charuluxananan et al., 2000).

6.7. Discussion

The purpose of the review was to describe current evidence on HIV/AIDS-related

stigma interventions among professionals and students from health-related

disciplines in order to shed light on the development of similar interventions for sex

workers. The majority of the included studies demonstrated promise in improving

the participants‘ knowledge, attitudes, and willingness to care for PLWHA. The

characteristics of the interventions and the implications for developing a stigma-

reduction intervention related to sex work are discussed below.

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Intervention approaches

All of the studies adopted a framework for developing interventions, with the social

cognitive theory and intergroup contact theory the most frequently adopted

frameworks. It has been suggested that theory-guided interventions are more likely

to produce significant results in improving behaviour than those not guided by theory

(Avery, Donovan, Horwood, & Lane, 2013; Noar, Black, & Pierce, 2009). It is

recommended that the social cognitive theory and intergroup contact theory be

adopted when developing interventions, in order to reduce the stigmatized attitudes

of health professionals towards sex workers.

This review identified various approaches that were employed in stigma-

reduction interventions for professionals and students in health disciplines. These

included the giving of information, the building of skills, counselling, contact with or

sharing by PLWHA, biomedical protection, and structural approaches. In the

majority of the interventions, various combinations of multiple approaches were

adopted, making it difficult to conclude which was the best combination of

approaches for reducing stigma. However, there was evidence that the single

approach of giving information over a short period was less likely to generate as

large effect size as interventions in which multiple approaches were used over a

longer duration. Thus, it is concluded that in interventions to reduce the stigmatized

attitudes of health professionals towards sex workers multiple approaches and a

longer duration / multiple sessions should be adopted to achieve the intended results.

Contact with and sharing by PLWHA was identified as the second most

commonly adopted approach in these interventions. This approach is also widely

used in interventions to reduce stigmatized attitudes towards other disadvantaged

populations or people with certain conditions, such as those with mental illness,

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sexual minorities, and patients with tuberculosis (Chaudoir, Wang, & Pachankis,

2017; Couture & Penn, 2003; Heijnders & Van Der Meij, 2006). This approach is

based on the intergroup contact theory (Allport, Clark, & Pettigrew, 1954). In this

theory, four conditions must be met for optimal intergroup contact: equal status,

common goals, intergroup cooperation, and institutional support (Allport et al.,

1954). It has been suggested that contact between healthcare providers and PLWHA

reduces prejudice toward the PLWHA (Mak et al., 2017). It is concluded that this

approach may also have the potential to reduce stigmatized attitudes toward specific

groups disproportionately affected by HIV, such as sex workers.

The findings from this review indicate that interventions are especially useful

in improving a participant‘s HIV/AIDS-related knowledge. However, the results

related to attitudes and behaviours were mixed, although the overall evidence was

positive. There was collinearity between the various dimensions of stigma (cognitive,

affective, and willingness to care), in that one dimension may affect the other

(Hanisch et al., 2016). Future studies should examine the relationships among these

various dimensions.

Outcome measures

Standardized measurements of knowledge, attitudes, and behaviours were lacking in

the intervention studies that were included. This was identified as an unsolved

problem in the field (Brown et al., 2003; Mahajan et al., 2008; Mak et al., 2017;

Sengupta et al., 2011; Stangl et al., 2013). Most of the studies used self-developed

measurements, and many failed to report on the validity and reliability of the

measurements. A recent review indicated that validated and standardized

measurements of attitudes toward sex workers are also lacking (Fitzgerald-Husek et

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al., 2017). The priority is to first define the various dimensions of stigma, and then to

develop standardized ways of measuring the effectiveness of stigma-reduction

interventions.

6.8. Limitations of the study

There are several limitations to the review. First, due to the heterogeneity of the

interventions, study design, and measurements, a meta-analysis could not be

conducted. Second, as many of the studies were rated as being of poor quality and

utilized invalidated measurements, the results should be interpreted with caution.

6.9. Summary

Overall, the review suggested the HIV/AIDS-related stigma-reduction interventions

among healthcare providers and students from health-related disciplines show

promise. These results imply that developing standardized measurements should be

the top priority in the development of an intervention to reduce stigma related to sex

work.

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 Chapter 7

The stigma of sex work and associated health care professionals and services

(Summary of the literature reviews and identification of research gaps)

[Link] findings

[Link] gap identified

[Link] and objectives of this study

[Link]

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The above literature reviews concentrated on five aspects: sex workers and

motherhood; attitudes of different stakeholders towards sex workers; barriers and

facilitators to the accessing of health services by sex workers; the conceptualization

of stigma and the stigma associated with sex work; HIV/AIDS-related stigma-

reduction intervention for professionals and students in health-related disciplines –

implications for stigma-reduction interventions related to sex work. It is based on an

extensive review of the literature. The research gaps in this area are identified.

7.1. Main findings

Sex workers and motherhood (Chapter 2)

Motherhood was an important identity for FSWs and influenced their lives, self-

esteem, and decisions. However, the stigma associated with sex work had a

significant impact on FSWs‘ identity as a mother, and subsequently their health and

their children‘s well-being. A more holistic approach is necessary to meet FSWs‘

multiple health, economic, and social needs. Services should be provided in a

sensitive and non-judgmental manner. Further, to advance the health and safety of

FSWs and their children, prostitution law may need to move toward

decriminalization of sex work. This review contributed to raising the awareness of

the general public toward FSWs as an individual and mother.

Attitudes of different stakeholders towards sex workers (Chapter 3)

Different stakeholders, including the law enforcement, professionals in health and

social services, clients of sex workers, and the general public health care providers,

held ambivalence, inconsistency, and even contradictory views toward sex workers

and prostitution laws. The negative attitudes of the stakeholders toward prostitution

might lead to increased occupational risks of sex workers. For example, the

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stigmatized attitude of health care providers may affect healthcare delivery for sex

workers and further result in sex workers‘ avoidance of treatment and deterioration

in their health. Interventions need to be implemented among different professional

groups who may affect the well-being of sex workers.

Barriers and facilitators to the accessing of health services by sex workers

(Chapter 4)

A wide range of barriers and facilitators at multiple socio-ecological levels could

influence sex workers‘ utilization of health care services, including intrapersonal,

interpersonal, institutional, community, and policy levels. Findings from this review

highlighted the importance of removing obstacles faced by sex workers in accessing

health services and combating stigma in healthcare settings. This information could

help policymakers, health care providers, and advocates for sex workers develop

acceptable, affordable, and accessible health services for sex workers. Also, health

services or future intervention studies should take into account the facilitators and

barriers identified in this review to improve the health services utilization and health

of sex workers, as part of the effort to protect the right of humans to health.

The conceptualization of stigma and the stigma associated with sex work

(Chapter 5)

This chapter reviewed the conceptualized of stigma. According to the social

cognitive model, stigma consists of three components: stereotype, prejudice, and

discrimination. There are three main levels of stigma: public stigma, self-stigma, and

structural stigma. Stigma has a significant impact on sex workers occupational health

and safety, and their health-seeking behaviours. One approach to improve their

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health care services uptake would be to change the health care providers‘ negative

attitudes toward sex workers.

HIV/AIDS-related stigma-reduction intervention for professionals and students

in health-related disciplines – implications for stigma-reduction interventions

related to sex work (Chapter 6)

HIV/AIDS-related stigma-reduction interventions among healthcare providers and

students from health-related disciplines showed promise. Common approaches

included giving of information, the building of skills, counselling, contact with or

sharing by PLWHA, biomedical protection, and structural approaches. Theory-

guided interventions were more likely to produce significant results in improving

behaviour than those not guided by theory (Avery et al., 2013; Noar et al., 2009). It

was recommended that the social cognitive theory and intergroup contact theory be

adopted when developing interventions, in order to reduce the stigmatized attitudes

of health professionals towards sex workers. The results also implied that developing

standardized measurements should be the top priority in the development of an

intervention to reduce stigma related to sex work.

7.2. Research gap identified

Based on the review of the literature, it is suggested that studies on the impact of the

stigma of sex work have been extensively studied, the study on the attitudes of health

care providers toward sex workers is limited in terms of the following aspects:

 Most studies mainly focused on the views of the general public attitudes

toward sex workers. Few studies focused on health care providers‘ attitudes

toward sex workers with HIV/STD symptoms (Chapter 3).

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  Although nurses are usually the first point of contact for clients and have

more interactions with patients than other health professionals. Scant research

focused on the attitudes of nurses and nursing students toward sex workers

and factors associated with their attitudes and behaviours (Chapter 3).

 Extensive studies have been conducted on the barriers to access health care

services among sex workers (Chapter 4). However, there is a shortage of

literature to understand the phenomenon from the perspective of sex workers

in Hong Kong.

 Although the stigma attached to sex work is prevalent in health care settings,

few interventions were found specially focused on reducing stigma towards

sex workers among professionals and students from health-related disciplines,

including nursing profession (Chapter 6).

7.3. Aims and objectives of this study

This study aims to examine the stigma of sex work and associated health care

services from the perspectives of sex workers, nurses, and nursing students in Hong

Kong, and to develop an intervention to reduce stigma towards sex workers among

nurses.

The objectives of this study are: (1) explore how sex workers experience

stigma and develop coping strategies when accessing health care services in Hong

Kong; (2) to explore the knowledge, attitudes, and willingness, of Hong Kong nurses

in relation to the issue of providing care for sex workers; (3) to examine and

compare students in the general and mental health nursing programmes in Hong

Kong in terms of their knowledge of, attitudes towards, and willingness to care for

sex workers in their future practice; and the factors associated with attitudes towards

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and willingness to care for sex workers among all nursing students, general nursing

students, and mental health nursing students; (4) to develop a conceptual framework

for reducing sex work-related stigma among nurses and nursing students; (5) to

develop an intervention to reduce stigma towards sex workers among nurses in Hong

Kong.

7.4. Summary

Theses reviews suggested that stigma reduction intervention may improve the health

and health care-seeking behaviours of sex workers. However, few interventions have

been explicitly identified on reducing stigma towards sex workers among

professionals and students from the health-related disciplines. To establish the

evidence needed to develop an intervention to reduce stigma towards sex workers

among nurses in Hong Kong, there is a need to understand the stigma of sex work

and associated with health care services from the perspectives of sex workers, nurses,

and nursing students.

The methodology of the study will be described in the next chapter.

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PART III THE STUDY CONDUCTED

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 Chapter 8 Methodology

[Link] of the study

[Link] and recruitment

8.2.1. Phase one

8.2.2. Phase two

8.2.3. Phase three

8.3. Ethical consideration

8.4. Data collection

8.4.1. Qualitative data

8.4.2. Quantitative data

8.4.3. Sample size

8.4.4. Validity and reliability of the questionnaire

8.5. Data analysis

8.5.1. Qualitative data analysis

8.5.2. Quantitative data analysis

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8.1. The methodology of the study

The stigma associated with sex work is a complex social phenomenon, and multi-

level factors could influence nurses and nursing students‘ attitudes toward sex

workers. Thus, it is concluded that a complex intervention, based on extensive

evidence, is needed to reduce stigma towards sex workers among nurses. The

Medical Research Council (MRC) framework on developing complex interventions

was used to guide the development of an intervention to reduce stigma towards sex

workers among nurses (Craig et al., 2008; Medical Research Council, 2019).

The first step of developing a complex intervention was to identify the

relevant evidence. An extensive review of the literature was conducted to identify the

existing evidence of the stigma of sex work and associated health care services.

Research design

To gain a better understanding of the complex social phenomena of the stigma

associated with sex work, this study adopted a mixed-method approach that

integrates both quantitative and qualitative research. There is an increasing

recognition of the value of mixed-method study in social, health, and behavioural

research (Creswell, Gutmann, & Hanson, 2003; Curry et al., 2013; Teddlie &

Tashakkori, 2009). It provides both broad general knowledge as well as deep insights.

It allows the researcher to investigate the studied problems at both macro and micro

levels (Foss & Ellefsen, 2002). It holds the potential for a rigorous and high level of

the complexity of the study (Creswell et al., 2003).

The study followed a sequential qualitative-quantitative design, in which

qualitative approach was conducted as an exploratory inquiry and followed by a

quantitative study that offered the researcher with a bigger picture to identify key

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factors/ issues for the development of a preliminary framework (Cameron, 2009;

Morgan, 1998). In this study, the information acquired from the qualitative study

reflected the attitudes and experiences of the sex workers and nurses, provided the

researcher a deeper understanding of the relevant key issues, informing the key

outcome measures to be included in the quantitative survey which provided the

researcher a better understanding of the extent of nursing student‘s knowledge ad

attitude towards sex workers,. It helped the researcher to understand the micro and

the macro level of the issue on hand.

This study was conducted in three phases. Firstly, a qualitative study was

conducted among the practicing nurses to collect information on their knowledge,

attitudes, and willingness, in relation to the issue of providing care for sex workers.

Secondly, another qualitative interview was conducted to include the voices of

female sex workers (FSWs) in an attempt to understand their health needs and

experiences with accessing health care services, and explore how they experience

stigma and develop coping strategies when accessing health care services. Thirdly, a

cross-sectional study was conducted to explore and compare students in the general

and mental health nursing programmes in Hong Kong in terms of their knowledge of,

attitudes towards, and willingness to care for sex workers

8.2. Sampling and recruitment

8.2.1. Phase one

After obtaining ethical approval for this study from the Human Subjects Ethics Sub-

committee of the Hong Kong Polytechnic University, the study started with phase

one during which a qualitative study was conducted among the practicing nurses. A

combination of convenience sampling and snowball sampling was adopted to recruit

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practicing nurses in Hong Kong. Convenience sampling was used to recruit

practicing nurses enrolled in master or doctoral programs in one of the three

universities in Hong Kong with a School of Nursing. This university has the largest

number of postgraduate nursing students in Hong Kong, with nearly 400 practicing

registered nurses studying for their master‘s or doctoral degree.

The subject teachers of the master‘s or doctoral program were approached

and asked to put aside some time at the beginning of their class to allow the

researcher (a non-teaching research student) to recruit potential participants. The

researcher first introduced herself as a postgraduate student in the School, then

provided information about the aim of the study before inviting the students to take

part in a focus group discussion. Those who were willing to take part were asked to

give their email contact details to the researcher and to indicate their availability on

some dates designated for group interviews. The potential participants were also

encouraged to invite their colleagues or classmates to participate.

The criteria for inclusion in the study were to be a practicing nurse; had the

ability to speak fluent Cantonese/Putonghua; be a Hong Kong resident, and to be

willing to be interviewed with informed consent. Those who were not able to speak

Cantonese/Putonghua; not Hong Kong Chinese or practicing nurses, and who were

unwilling to be interviewed were excluded.

8.2.2. Phase two

In phase two, individual interviews were conducted with FSWs. FSWs are a hard-to-

reach population. Since local NGOs had established a relationship of trust with

FSWs, the potential participants were recruited with the support of NGOs, including

the Action for Reach Out (AFRO) and the JJJ Association. These organizations focus

127
on the social inclusion of FSWs and assist them in dealing with health, safety, legal,

and human rights issues. They also run outreach teams and are in regular contact

with a number of FSWs throughout the city. One of the authors received training

from NGOs and worked with them during outreach activities, campaigns, and events

related to sex workers‘ rights. The long-term relationship between the author and

NGOs contributed to the success of recruitment.

A combination of convenience and snowball sampling techniques were used

to recruit the FSWs. The staff of NGOs accompanied the researcher to reach the sex

worker. In fact, many sex workers were referred by another sex worker through a

snowball sampling method. Many of them had never visited NGOs or talked with the

staff of NGOs before the interview. Each FSW was offered HK$400 (US$1 USD ≈

HK$7.8) as compensation for their time and willingness to share their experiences in

seeking health care.

The criteria for inclusion in the study were FSWs who were: 1) over 18 years

of age; 2) currently engaged in sex work, defined as having offered to perform at

least one sexual service for money within the last four weeks; 3) able to speak

Cantonese/Putonghua; and 4) able to give informed consent. Excluded from the

study were: 1) those unable to speak Cantonese/Putonghua; 2) who had been

diagnosed with and were currently undergoing medical or psychological treatment

for a serious psychological health problem such as psychosis, bipolar disorder,

and/or severe affective disorder; 3) who had self-reported current suicidal ideation

and/or attempts; 4) who refused to give their informed consent to participate in the

study.

A safe and comfortable environment was essential to ensure the safety for

both FSWs and the interviewer. The interview took place at the office of one NGO or

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at one-woman brothels accompanied by an NGO staff member. Also, due to the

sensitive nature of the topic, the ―same-gender‖ interviewing was considered

beneficial to build rapport between the researcher and the participants. All the

interviews were conducted by a female research student who came from a

postgraduate research background and had received qualitative interview training

during her master of public health and doctor of philosophy programmes. The

research student was a registered nurse, who had experience in providing sexual and

reproductive health care services to FSWs at the local NGO, and had gained rich

experience in talking with FSWs in a sensitive, open, and non-judgmental manner.

Moreover, the research student had received Mental Health First Aid training in

Hong Kong, and the skills that she had learnt from the course helped her to assess

the mental health of the participants during the interview.

The researcher did not contact FSWs directly. Instead, the staff of NGOs

contacted potential participants directly via phone calls or during outreach activities

and provided them with the information sheet and the consent form of the study.

They described the aims of the study, went through the information sheet, and

invited FSWs to participate. Once the potential participant agreed to participate, the

staff of NGOs confirmed with the research student about the eligibility of the

participants, the interview date, time, and venue by email or instant message (i.e.,

WhatsApp).

Before the interview started, the research student started the conversation

casually to establish rapport with the participants. Then, the research student

explained the aims of the project and checked potential participants for eligibility.

She then invited those who were eligible to participate and obtained their informed

consent prior to conducting the interview.

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 The author would disseminate the results to the participants upon their

request. The participants were given options for receiving the research findings from

journal papers, seminars, one-on-one meetings, and other social media (i.e. Facebook,

Twitter, WeChat, or WhatsApp). Also, the two NGOs would be involved in the

dissemination of the findings of the study to FSWs community and healthcare

organizations.

8.2.3. Phase three

After completing the qualitative interviews with nurses and FSWs, in phase three, a

cross-sectional survey was conducted among the undergraduate students. The

sampling frame for participants in the survey was all students enrolled in two

Bachelor of Science Honours Degree in Nursing programmes (General Nursing and

Mental Health Nursing) at one of the three major universities in Hong Kong. This

university has the largest number of nursing students in Hong Kong. There were a

total of 850 general nursing students and 350 mental health nursing students in the

undergraduate programme. All students were aged 18 or above, studying full time,

and almost all possessed a smartphone.

Undergraduate nursing students were recruited during the regular full class

meeting with programme leaders held at the beginning of each semester. The non-

teaching researcher (a PhD student) from the School of Nursing explained the aim of

the study. The programme leaders also helped to remind students to take part in the

study via a mass email.

8.3. Ethical considerations

Ethical approvals of the three studies were obtained from the Human Subjects Ethics

Sub-committee of the Hong Kong Polytechnic University. The written approval

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(email) of the qualitative study among FSWs was also obtained from the ethical

review board of NGOs.

In phase one and two, written consent was obtained from nurses and FSWs

before the commencement of the study. In phase three, nursing students who scanned

the QR code and submitted a completed questionnaire were considered to have given

their implied consent to take part in the study. The participants were informed of

their right to withdraw at any time during the interview, and their participation was

voluntary. They were assured of dignity, privacy, confidentiality, and anonymity in

their participation in the study. Only numerical identifiers were used to protect the

identity of the participants.

To minimize the risk of emotional disturbance when discussing sensitive

topics, the researcher closely observed the participants‘ psychological responses. In

addition, at the end of each focus group discussion among nurses, the participants

were given time to engage in an informal discussion. The nursing students were

given contact information to access the psychological support and counseling

services available at the Office of Counseling and Wellness of the University. They

were also given the number of a crisis hotline.

The interviews among FSWs were conducted with caution and with the

guidance and support of the NGOs. The risk that the FSWs encountered as

participants in the study was no greater than what they would experience in their

everyday life, as this study primarily focused on their health care needs and

experiences with health care services. Staff from the NGOs helped to monitor the

emotional reactions of the FSWs during the interview and provided psychological

support to the participants if needed. The FSWs were also offered the number of a

crisis hotline.

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 All of the research data were stored in locked cabinets. The electronic data

were protected using a password. Only the researcher could access the data.

8.4. Data collection

The study was conducted after receiving ethical approval from the Human Subjects

Ethics Sub-committee of the Hong Kong Polytechnic University and the ethical

review board of NGOs.

8.4.1. Qualitative data

Both focus group discussions and individual interviews were adopted as methods for

collecting data among nurses. A focus group discussion approach was adopted to

facilitate the generating and sharing of ideas among the participants. Individual

interviews were used to collect detailed individual accounts of the attitudes and

beliefs of the participants. Both methods provided the researchers with valuable

insights into people‘s attitudes and practices (Kaplowitz & Hoehn, 2001). Besides,

individual interviews among the FSWs was chosen because such an approach is

considered best suited to topics that are sensitive in nature (Kaplowitz & Hoehn,

2001).

The semi-structured interview was used, as it is considered as a flexible tool

to capture the voice and experience of the participants. This method uses a prepared

interview guide, but the open-end and probing questions are flexible to allow the

participants to recount their experience and even expand the original questions and

responses (Al-Busaidi, 2008; Mishler, 1991).

The semi-structured interview guide of the study was developed by the

research student based on a review of the literature and on her previous experience

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with working and volunteering at an NGO that offers health services to FSWs. The

proposed questions were further discussed with a university professor who is an

expert in women‘s health and with the service in-charge of the NGOs, who is a social

worker.

In the interviews, the interview questions were only used as a guide; the

discussion was not restricted to the issues raised in those questions. However, the

research student ensured that the discussions remained on topic.

The interview questions for nurses included asking the practicing nurses what

they thought of people who engage in sex work, how they saw their duty as nurses in

caring for these people, the provision of their nursing care, when there was a patient

whom they suspected, was involved in sex work, and whether they were prepared to

take care of these patients (See Appendix X-Interview Guide).

The interview guide for FSWs covered the following topics: FSWs‘ health

and service needs, access to and experience with health care services, the attitude of

health professionals, the disclosure of the FSWs‘ status in the health care settings,

and whether they had any recommendations for better health care services (See

Appendix XII-Interview Guide).

All of the interviews were conducted in Cantonese (a dialect commonly

spoken in Hong Kong) or Putonghua. Most of the individual interviews were audio-

recorded with the consent of the participants. Five FSWs refused to be recorded

during their interviews, and handwritten notes were taken during those interviews. In

addition, communication with a hearing and speech impaired FSW was conducted by

writing notes on a computer. The numbers of focus group discussions and FSWs

were determined by data saturation (i.e., when no new findings or concepts emerged

from the interviews).

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8.4.2. Quantitative data

In phase three, students were invited to take part in the survey by using the

university‘s ‗MySurvey‘ platform. A Quick Response code (QR code) was created

for the ‗MySurvey‘, and shown to the students using a PowerPoint slide. The

students were instructed to access ‗MySurvey‘ after scanning the QR code with their

smartphones. Students who scanned the provided QR code and submitted the survey

were considered to have given their consent to participate in the study.

The preliminary questionnaire was developed based on extensive literature

review and findings from the qualitative interviews among nurses and FSWs in the

previous two phases, and was further validated by experts. The questionnaire was

comprised of eight sections: 1) the socio-demographic information of the students; 2)

their knowledge of sex workers; 3) the Attitudes toward Prostitutes and Prostitution

Scale; 4) the nursing students‘ attitudes towards sex workers; 5) their support for the

human rights of sex workers; 6) their willingness to care for sex workers in their

future practice, 7) their cultural competence in caring for sex workers; 8) their

educational needs in caring for sex workers.

Section 1 of the questionnaire solicited the socio-demographic information of

the students, including their age, gender, birthplace, religion, years of study, and

programme of study.

Section 2 contained seven questions developed by the researchers of this

study to explore the students‘ knowledge of prostitution law, whether they had ever

attended a related lecture or seminar, their perceived level of knowledge of sex

workers, and their educational needs in caring for sex workers. The response formats

used in this section varied. For example, four dichotomous items related to their

personal contact with sex workers and perceived need to learn about sex workers

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were answered in by a yes/no response. The hours of sex-work related education and

self-rated knowledge about caring for sex workers were measured on a 3-point

Likert-type scale. The knowledge of prostitution law was asked with multiple

possible answers provided.

Section 3 consisted of the 29-item Attitudes toward Prostitutes and

Prostitution Scale (Levin and Peled, 2011). The scale contains two subscales on

prostitutes: as normative / deviant (8 items), and as choosing / victimized (6 items).

Two subscales on prostitution: as normative / deviant (8 items), and as choice /

victimization (7 items). The items are measured on a 5-point Likert-type scale (1 =

strongly disagree, 5 = strongly agree). Agreement with each statement indicates a

belief in deviance / victimization. Disagreement with each statement suggests a

normative view of sex workers, with sex work regarded as a choice. The Cronbach‘s

alpha reliability of the four subscales ranged from 0.81 to 0.88, and was 0.81 for the

overall scale. Permission to use this scale was obtained from the authors.

Section 4 was the scale measuring the nursing students‘ attitudes toward sex

workers, which was adopted from a scale developed by Melby V et al. (1992) to

determine nurses‘ attitudes towards prostitutes. A 5-point Likert-type scale was used,

with 1 = strongly disagree, and 5 = strongly agree. The scale on nursing students‘

attitudes was comprised of eight items on attitude, with three related to morals, two

to control, and three to sympathy. Negative items (Items 2 to 7) were reversely coded,

with higher scores representing positive attitudes, and lower scores representing

negative attitudes toward sex workers. The psychometric properties of the scale were

not reported in the literature. Permission to use this scale was obtained from the

authors.

Section 5 assessed levels of support for the human rights of sex workers. The

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nine items in this section were developed based on notions concerning women‘s

sexual and reproductive health and rights as laid out by the United Nations‘ Office of

the High Commissioner for Human Rights (The Office of the High Commissioner of

Human Rights, 2014). Responses were measured on a 5-point Likert scale (1 =

strongly disagree, 5 = strongly agree). The total score of the scale ranged from 9 to

45 points, with a higher score indicating more support for the human rights of sex

workers.

Section 6 focused on the students‘ willingness to care for sex workers. The

scale was developed based on previous studies assessing the willingness of nursing

students to treat people living with HIV/AIDS in Hong Kong (Yiu, 2010). It contains

three items: (1) If I am allowed to choose, I would not choose to serve patients who

are sex workers; (2) I would refuse to care for patients who are sex workers; (3) I am

willing to take care of patients who are sex workers. Responses to each item ranged

from 1 (strongly disagree) to 5 (strongly agree). Items one and two were reversely

scored, with a higher score representing a greater willingness to care for sex workers.

The Cronbach‘s alpha was reported to be 0.81 in the pre-intervention phase and 0.80

in the follow-up phase of the previous study (Yiu, 2010).

Section 7 consisted of the Cultural Competence Assessment Tool developed

by Doorenbos et al. (2005) to assess the cultural competence of nursing students in

caring for sex workers (Doorenbos, Schim, Benkert, & Borse, 2005). The scale

consists of 25 items that measure cultural awareness, cultural sensitivity, and cultural

competency behaviours. A 5-point Likert scale was used to assess the cultural

awareness and sensitivity in a response set of strongly agree, agree, no opinion,

disagree, and strongly disagree. Cultural competency behaviours were assessed using

a 5-point Likert scale in a response set of always, often, at times, never, and not sure.

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The scores were summed up and transformed into a 1 to 125 scale, with a higher

score representing a higher level of cultural competency in caring for sex workers.

The Cronbach‘s alpha was reported to be 0.86 in previous studies (Doorenbos et al.,

2005).

Section 8 contained only two items, developed by the research team, for

assessing the educational needs of nursing students in caring for sex workers: 1) Do

you think the topic of sex workers should be addressed in the undergraduate nursing

curriculum? (Yes / No). 2) Which educational approach would you prefer to acquire

knowledge related to caring for sex workers? (Multiple possible answers were

provided).

8.4.3. Sample size

The ratio of 15 subjects per predictor variable was adopted to calculate the sample

size among the nursing students (Stevens, 2012). It was estimated that the maximum

number of predictors in the regression would be 20. Thus, the estimated sample size

of the study was 300.

8.4.4. Validity and reliability of the questionnaire

Content validity

The validity and reliability of the questionnaire were tested before the online

‗MySurvey‘ study was conducted. The content validity of each item and the scales

were assessed by a panel of six experts comprising two experts in women‘s health,

one in mental health, one in cultural sensitivity, one in nursing education and cultural

sensitivity, and one in social work with sex workers.

The experts were asked to rate each item using a 4-point scale: 1 = not

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relevant; 2 = somewhat relevant; 3 = quite relevant; and 4 = highly relevant. The

content validity index (CVI) for each item (I-CVI) and the entire scale (S-CVI) were

calculated. For each item, I-CVI was calculated based on the number of experts

giving a rating of either 3 or 4 divided by the six experts. For each scale, the S-CVI

was calculated by averaging the I-CVI for all items on that scale. Items with an I-

CVI of at least 0.78 and scales with an S-CVI of at least 0.90 were deemed to meet

the criteria for inclusion in the questionnaire (Polit, Beck, & Owen, 2007; Waltz,

Strickland, & Lenz, 2010). Items and scales that failed to meet the I-CVI / S-CVI

criteria were removed from the questionnaire. The items were also amended

according to comments and suggestions from the experts. For example, two experts

edited the wording of a few items for clarity, and one added an item relating to

support for the human rights of sex workers.

The results of the content validity test of the measurements are shown in

Appendices Table 8-1. All of the items on the nursing students‘ knowledge of sex

workers and prostitution law, attitudes toward sex workers, support for the human

rights of sex workers, willingness to care for sex workers, and educational needs

demonstrated adequate content validity, with I-CVIs ranging from 0.83-1.00, and S-

CVIs of 1.00, 0.963, and 1.00, respectively. One of the items in the attitudes toward

prostitutes and prostitution scale was considered inappropriate, with an I-CVI of

0.667, and was removed. The S-CVI of the scale was 0.891, and the scale was

removed from the questionnaire.

The S-CVI for the cultural competence scale was 0.833, with five out of the

25 items having an I-CVI of as low as 0.17 to 0.33 and less than 0.78. Two experts

on cultural sensitivity questioned the use of the cultural competence scale in the

survey. They also pointed out that cultural competence has been criticized for leading

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to the stereotyping of cultural groups (Kleinman, 2006). They also voiced the

suspicion that cultural competence would be low among undergraduate nursing

students, as experience and exposure are required to develop cultural competence.

On the suggestion of all of the experts in the panel, the cultural competence scale on

caring for sex workers was removed from the questionnaire.

Pilot study: reliability of the questionnaire

A pilot study was conducted to establish the reliability of the questionnaire. A total of

20 undergraduate nursing students were invited to complete the questionnaire in

January 2019. Internal consistency was measured by Cronbach‘s alpha. The two-

week test-retest reliability was estimated using the intra-class correlation coefficient

(ICC). A Cronbach‘s alpha α value of less than 0.50 is regarded as unacceptable, 0.50

- 0.60 as poor, 0.60 - 0.70 as acceptable; 0.70 - 0.90 as good; and over 0.90 as

excellent (Nunnally & Bernstein, 1967). An ICC value of ≤ 0.4 is considered poor;

0.41 - 0.60 moderate; 0.61 - 0.80 good; and 0.81 - 1.00 excellent (Nunnally &

Bernstein, 1967). Minor changes were made based on the participants‘ feedback on

clarity. The individuals who were involved in the pilot study were not included as

study participants in the main study.

The psychometric properties of the measurements are shown in Appendices

Table 8-2. The findings indicate that the measures used in the study had acceptable

internal consistency (α=0.653 to 0.967) and an excellent level of stability

(ICC=0.844 to 0.911) within the two-week period.

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8.5. Data analysis

8.5.1. Qualitative data analysis

According to Kimberly A. Neuendorf, content analysis ―fits the positivism paradigm

of social research. The goal of the scientific methods is generalizable knowledge,

with the concomitant functions of description, prediction, explanation, and control.‖

(p.18) (Neuendofr, K.A., 2016). Content analysis is used to detect manifest and

latent meaning from data, and is considered as a flexible way for analyzing text data.

Conventional content analysis of qualitative study among nurses

Conventional content analysis is generally used with a study design whose aim is to

describe a phenomenon. This type of design is usually appropriate when an existing

theory or research literature on a phenomenon is limited. Researchers avoid using

preconceived categories, instead of allowing the categories and names for categories

to flow from the data. It is an inductive category development. There is a lack of

literature on the attitudes and willingness to care for sex workers among nurses or

other health care providers. Thus, this approach was adopted in the qualitative study

among nurses.

In this process, the transcriptions were read by two researchers independently

without any attempts to conduct coding, to obtain an overall picture of the interview.

Next, different segments of the text were fractured into meaning units and assigned a

code. A meaning unit is the smallest unit that contains aspects related to each other

through their content and context. It could be words, phrases, or sentences. Codes

were chosen to retain the core meaning of the participants‘ experiences. The codes

were then grouped into subcategories and main categories.

Individual interviews were only used to collect detailed individual accounts

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of the attitudes and beliefs of the participants who were not available for focus group

discussions.

Three individual interviews were conducted among a mental health nurse

who was also a sexual therapist, and two staff from the social hygiene clinics. The

three participants had the experience of taking care of sex workers. Because it was

difficult to organize focus group discussions among the three key informants, they

were interviewed separately.

Directed content analysis of qualitative study among FSWs

Directed content analysis is adopted when ―the existing theory or prior research

exists about a phenomenon that is incomplete or would benefit from further

description‖ (p.1281) (Hsieh & Shannon, 2005). This is considered as a deductive

use of theory. The present study started with the previously developed

conceptualization of self-stigma and aimed to explore the experience of the stigma of

FSWs when accessing health care services. The predetermined coding categories for

stigma from the literature were: experienced, anticipated, and internalized stigma.

Besides, the classification of coping behaviours has been extensively studied, it

could be divided into two general categories: active coping and passive coping.

Therefore, a directed content analysis was adopted to analyze the interview data and

field notes.

First, the transcriptions and field notes were read by two researchers

independently without any attempts to conduct coding, to obtain an overall picture of

the interview. The meaning units related to the participants‘ experiences of stigma

and coping strategies were identified and highlighted, which included simple and

clear phrases and sentences, such as ―bad attitudes‖, ―I feel ashamed of myself‖, ―I

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feel stressed on the way to the clinic‖, etc. After that, the meaning units were coded

with the predetermined coding categories if possible. The data that could not be

coded in these categories were coded with other categories and themes by adopting

the inductive approach. The two researchers discussed the resulting themes until they

reached a consensus. Once no new concepts emerged from the data, the researchers

re-examined the data and agreed upon a number of higher-order themes. Only after

the themes were identified and confirmed were the quotations translated into English

by the researchers for use in writing the report. The number at the end of each quote

refers to the number assigned to the individual who was interviewed.

In the qualitative study, member checking is considered as a crucial technique

to ensure the accuracy, credibility and validity of the results. It was performed after

the data analysis of the study. All the participants were invited to review the analyzed

data and gave comments on the accuracy of the interpretation.

Techniques to ensure the accuracy and veracity of the translation

Due to the sensitive nature of the topic, the study did not involve a translator. Instead,

the research student, who is fluent in both English and Chinese, worked as an analyst

and translator.

Full engagement in the research helped the research student make the

analytic and translation process more transparent and minimize the risks of

misinterpretation during translation. The original data was firstly analyzed in

Chinese. Then, the subthemes and theme were developed in Chinese. After that, the

data was translated from Chinese to English, and the subthemes and themes were

developed in English. The two versions of quotes, codes, subthemes, themes were

compared.

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 To further ensure the accuracy and veracity of the translation, the research

student further discussed the translated data, coding, subthemes, and themes with a

professor, who was fluent in both languages.

Only after the themes were identified and confirmed were the quotations

translated into English by the researchers for use in writing the report. The FGD or II

found in brackets at the end of each quote refer to focus group or individual

interviews respectively, with the number referring to the number of the group or

individuals who was interviewed.

8.5.2. Quantitative data analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS v. 25).

The frequencies, percentages, means, standard deviations, and median were explored

with descriptive statistics. An independent sample t-test was used to compare the

mean values of the continuous variables, and a chi-square test was used to compare

differences in the proportions of categorical variables between the general nursing

students and the mental health nursing students. A stepwise multiple linear regression

was conducted to identify factors associated with the attitudes and willingness of

students to care for sex workers. A p-value of < 0.05 was considered to be

statistically significant.

Figure 8-1 illustrates the steps taken and studies conducted corresponding to

the MRC framework in developing a complex intervention.

The following three chapters will present the study results and discussion

according to the three phases of the study process.

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 Process of MRC framework Studies conducted

 Literature review: Conducting a series of an extensive

Step 1 review of studies related to the stigma of sex work
Identifying the (Chapter 2-4, 6), review the definitions and
evidence base conceptualizations of stigma (Chapter 5)
 Study I: Conducting a qualitative study on the
perspectives of practicing nurses toward caring for sex
workers in Hong Kong (Chapter 9)
 Study II: Conducting a qualitative study on the
experience of female sex workers with accessing health
care services in Hong Kong (Chapter 10)
Phase 1
 Study III: Conducting a cross-sectional study on the
Developing the
knowledge of, attitudes towards, and willingness to care
complex intervention
for sex workers among the undergraduate nursing
students (Chapter 11)

Step 2 Proposing a preliminary conceptual framework to

Identifying / understand the stigma toward sex workers among nurses
developing theory (Chapter 12)

Step 3 Developing and presenting the related contents of the reduce

Modelling process the stigma towards sex workers among nurses programme
and outcomes (Chapter 13)

Figure 8-1 Steps taken and studies conducted corresponding to

MRC framework in developing a complex intervention

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 Chapter 9

STUDY I Caring for female sex workers:

a qualitative study on perspectives of practicing nurses in Hong Kong

[Link]

9.1.1. Participants‘ characteristics

9.1.2. Themes that emerged from the interviews

[Link]

[Link]

[Link]

*Content of this chapter is submitted:

Ma, P. H., & Loke, A. Y. (2019). Caring for female sex workers: a qualitative study

on perspectives of practicing nurses in Hong Kong. Under reviwe at AIDS Care

Psychology, Health & Medicine Vulnerable Children and Youth Studies. (AIDS Care,

submitted 22nd Mar, 2019).

145
In phase one, from April to July 2018, seven semi-structured focus group discussions

were conducted among 33 practicing nurses, with three to six nurses in each

interview group. Five focus group discussions were conducted at the school of

nursing, and two focus group discussions were conducted in hospitals. The focus

group discussions lasted from 63 to 123 minutes. Individual interviews were

conducted with three key informants, including a mental health nurse who was also a

sex therapist, and two nurses currently working in a social hygiene clinic. Two

interviews were carried out at the school of nursing, and one interview was

conducted at the social hygiene clinic. Individual interviews lasted from 40 to 139

minutes.

9.1. Results

9.1.1. Characteristics of the participants

The 36 participants were working in a range of outpatient/inpatient health care

settings in Hong Kong, including the social hygiene clinic, department of obstetrics

& gynecology, psychiatric unit, general out-patient clinics (GOPC), occupational

health unit, neonatal intensive care unit (NICU), operating theatre, hematology unit,

intensive care unit (ICU), orthopedics unit, dermatology clinic, and old-age homes.

The participants were 21 to 63 years of age, and had four months to 40 years

of experience. Well over half of the participants were female (69.4%), and half were

single. The majority of them were registered nurses (88.9%), and over 80% had

received a university education or above. Only two psychiatric nurses and a nurse

from a social hygiene clinic had received on-the-job training on working with sex

workers. A gynecology nurse received training on sex work in her certificate course

on sex therapy.

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 Only nine participants reported that they had ever taken care of sex workers

in their health care settings or of someone who may have been involved in sex work.

These were four psychiatric nurses working in psychiatric units, two nurses working

in social hygiene clinics, two nurses from the obstetrics & gynecology department,

and one nurse from the general outpatient clinic.

9.1.2. Themes of the study

Content analysis of the interview transcriptions revealed four major themes: (1)

generally conflicting attitudes toward sex workers; (2) the professional obligation to

provide care to all; (3) acknowledgment of one‘s hesitation in caring for sex workers;

and (4) the preparations involved in caring for patients who might be involved in sex

work. Examples of meaning units, summarized meaning units, sub-theme and theme

are presented in Table 9-1.

Overall, the nurses showed conflicting attitudes toward sex workers. While

they understood that their professional code of ethics stipulates that all patients

should be treated equally, they hesitated to provide care for sex workers. There were

also barriers preventing them from providing optimal care to sex workers. However,

only a few of the nurses agreed that training should be provided to equip nurses with

the competency to provide care to those who might be involved in sex work.

Theme 1: Generally conflicting attitudes toward sex workers

Generally speaking, the nurses apparently held various attitudes toward sex workers.

The majority of the participants normalized sex work and considered it to be driven

by ―supply and demand.‖ They regarded sex work as having had a long history and

as unlikely to disappear. Some nurses believed that sex work was a personal choice.

147
Three had no hesitation admitting that they had friends who worked as prostitutes.

By contrast, a few nurses viewed sex work as an act of male exploitation of women‘s

bodies and were clearly opposed to sex work. Nevertheless, the majority of the

nurses who were interviewed believed that anyone could easily spot sex workers in

the street by the provocative manner in which they dressed or behaved.

Meanwhile, the majority of the participants also showed conflicting and

ambivalent attitudes toward sex workers. Although some alleged that they had an

open mind toward ―sex work,‖ they would disapprove of such work as an individual,

and would not accept having family members or close friends who did sex work or

made use of the services of sex workers. For example, one said:

On one hand, I see sex workers as vulnerable people, and think that there

must be a sad story behind their selling their bodies for money. But there was an

incident when I first learned that a friend of mine since childhood was working in a

nightclub as a prostitute – without thinking, it just popped out of my mouth to ask

why she wanted to do that kind of dirty job. (FGD1-5, female general nurse,

occupational health department, 42y)

The majority considered sex work to be immoral. They stated clearly that

they could not accept any variations in engagement in sex work. For example:

There are young girls nowadays who would go out on dates with strange men

in exchange for money/gifts of what they want. They do not think that there is

anything wrong in such a money-sex exchange. To me, this is a different kind of

“prostitute.” I think many of us cannot accept this “choice” for making money.

(FGD5-1, female obstetrics & gynecology nurse & sex therapist, lecturer, 44y)

Moreover, influenced by news reports, some held ambivalent attitudes

towards sex workers. As one nurse said:

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 I thought that most sex workers are no longer forced into this kind of work.

These people just choose to make quick and easy money. Then, one day I read from a

news report in China that some young girls were forced to do sex work against their

will. I now have mixed feelings towards them. (FGD5-5, general nurse, lecturer, 37y)

There was also an association between being a sex worker and contracting

HIV. A few argued that everyone was at risk of getting HIV without protected sex,

and some even contended that sex workers might be less likely to contract HIV since

they were aware of the need to protect themselves and therefore would take

precautions. However, a nurse from a general outpatient clinic (GOPC) said that she

associated HIV with sex workers.

When we learn of a patient with a confirmed diagnosis of HIV or who is

referred to the social hygiene clinic, then we often think that the person is likely to be

a sex worker. (FGD1-4, female GOPC nurse, 35y)

A nurse who was previously working in a social hygiene clinic caring for sex

workers had a different attitude towards sex workers, but he confessed that his

attitude has changed.

When I was a general nurse, I admit that I was prejudiced against sex

workers. As I learned more about them and started to care for these people, I

realized that I should not discriminate against them. These people generally suffer

from low self-esteem and have had unhappy life experiences. (II-1, male nurse,

social hygiene clinic, 63y)

The same nurse believed that these people chose sex work because they had

no other option, and that they were a vulnerable group of people who needed to have

the acceptance and empathy of others.

There are many sex workers from the mainland who married older men in

149
Hong Kong, but the marriage did not last. They have to leave their children in China

with their own family and work as a sex worker to make money to support their

children and family back home. (II-1, male nurse, social hygiene clinic, 63y)

The interviews revealed that the majority of nurses, as members of the

community, had a similar attitude towards sex workers as that held by the general

public. They judged sex work as immoral, and saw it as a way that many use to make

quick and easy money. Although they claimed to be open-minded, they would not be

able to accept it if family members or friends chose sex work. Only when nurses

started to care for sex workers and came to learn about their sufferings did they start

to change their view of sex workers and develop an empathetic attitude towards them.

Theme 2: The professional obligation to provide care to all

All of the nurses who were interviewed asserted that they had all been taught in their

nursing education to provide fair treatment to all people. They declared that there

was a code of professional ethics for nurses, and that they understood that their

responsibility was to provide care to all patients regardless of their background,

including sex workers.

Some nurses elaborated by emphasizing the ―heroic‖ nature of the nursing

profession of providing care to patients, even to the extent of risking their own health.

They gave an example of nursing professionalism the actions demonstrated by

nurses during the epidemic of the severe acute respiratory symptom (SARS) in Hong

Kong in 2003.

Nurses should shoulder the responsibility to maintain professionalism.

During SARS, nurses stayed in hospitals to care for patients, even knowing that they

risked being infected. We can only do our best to adhere to precautionary procedures

150
to prevent contracting infections. It is our responsibility to take care of patients, and

be prepared to face the risks. (FGD2-4, female ICU nurse, 35y)

Nurses in the interviews said that they would not probe into a patient‘s work

except in the case of a needle stick incident, which might put them at risk of

contracting an infection.

We are professionals, and have a responsibility to serve all without

considering their background or occupation. That’s the expectation of our nursing

profession. If we encounter someone with suspected HIV or a sex worker, we take

universal precautions as usual for all our nursing care. (FGD1-5, female general

nurse, 42y)

There were moments at work that nurses experienced feelings of ambivalence,

both personally and professionally. Some nurses were aware of this and tried to

provide professional care while suppressing their personal views.

I am a professional nurse, yet I am also a woman. Although professionally, I

think I can provide equal nursing care to all patients, yet once in a while, the

patient’s sex work will pop up in my mind, and I keep telling myself that I shouldn’t.

(FGD1-5, female nurse, occupational health department, 42y)

While the majority of the nurses considered themselves to be upholding the

code of professional ethics in providing equal care to sex workers, a nurse working

in the social hygiene clinic and another psychiatric nurse both questioned whether

nurses gave out verbal and non-verbal cues that betrayed prejudice towards sex

workers. The two nurses expressed the opinion that although many nurses attempted

to behave in a professional and desirable manner, as a matter of fact, their tone of

voice, facial expression, physical distance, avoidance of direct eye contact,

avoidance of attention, or other subtle non-verbal behaviours unintentionally showed

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an attitude of stigmatization towards sex workers. They questioned whether there

was a disparity between the care provided by the nurses and their deeply rooted

discriminatory attitude.

Generally speaking, nurses may try very hard to adhere to their professional

code of ethics, since they have learned from their education and training that this is

what they should do. But I doubt if nurses can really provide equal care to all

patients. I remember when I was working in a hospital, many nurses kept a distance

from those they believed were sex workers when giving penicillin injections. I also

witnessed co-workers who intentionally or unknowingly neglected sex workers when

they learned about their sexually transmitted disease (STD) status. (II-1, male nurse,

social hygiene clinic, 63y)

This theme revealed that all nurses knew that it was in their professional code

of ethics to care for all patients, and they worked very hard to provide equal care as a

way to avoid receiving complaints. Some were aware of their inner ambivalence, and

of potential differences between what they thought of the care that they provided and

the deeply rooted discrimination that they might have conveyed.

Theme 3: Acknowledgment of one’s hesitation in caring for sex workers

Despite the ambivalence or alleged open-mindedness that they displayed towards sex

workers and despite observing the profession‘s code of ethics, the majority of the

participants acknowledged their hesitation in caring for sex workers.

There were nurses who realized the conflict between their personal values

and their professional duties. This inner struggle led to hesitation in caring for sex

workers.

I don’t feel pity for those who choose to do this kind of work for easy and

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quick money and then contract STDs or HIV. I do feel reluctant to take care of them,

but I cannot discriminate against them outwardly, and must continue to provide the

needed nursing care. (FGD1-3, female general nurse, 30y)

Some nurses felt compassion for the sex workers, and wanted to express their

empathy and help them. But many were worried that they did not know how to do so,

and thought that it might ruin the therapeutic relationship if they approached sex

workers directly. They tended to play it safe and avoided raising sensitive topics.

I have empathy for sex workers. Although sometimes I would like to know

more about these patients, I dare not ask because I am afraid that they might think

that I am being nosy or discriminating against them. (FGD1-4, female GOPC nurse,

35y)

Some of the interviewed nurses pointed out that, sometimes, it was not the

background of the clients that affects their willingness to care for them, but the

clients‘ characteristics and attitudes. An obstetrics & gynecology nurse and sex

therapist said:

There was one time when I was taking care of a teenage sex worker who had

been diagnosed with an STD. I wanted to teach her about safe sex and condom use.

She glanced at me and said offensively that it was none of my business. Her rudeness

made me angry and I could not continue to do what I thought I should as a nurse

caring for her. (FGD5-1, female obstetrics & gynecology nurse & sex therapist,

lecturer, 44y)

Nurses also commented that because of self-stigma, sex workers might be

sensitive to what they did or said. They believed that sex workers often

misunderstood what it was that nurses did and worried about being ―judged‖ by

others.

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 We may wear a mask or gloves because of their infectious disease, but they

take that as an indication that they are considered “dirty.” The things that we say

might not have any bad intention, but be regarded as discriminating against them.

They are very sensitive to what we say and to our actions. I just don’t know how to

handle them. (FGD1-3, female nurse, general nurse, 30y)

Most nurses believed that sex workers usually hid their identity due to self-

stigma and to the fear of not being accepted, but that created a barrier to

communication. Their identity was usually not confirmed unless the clients were

willing to reveal it; nurses would find it too a sensitive an issue to ask.

Many of this kind of patients will not fill in their occupation on the

admission/intake form, or tell us what it is. We won’t know for sure if they are sex

workers, but can only guess. This is a sensitive topic to touch on, but it creates a

barrier to communication and to conduct appropriate investigations. (FGD1-4,

female GOPC nurse, 35y)

Those nurses who were in frequent contact with sex workers at work believed

that nurses should be sensitive to the patient‘s work, since it affected the patient‘s

health, and because nurses had the opportunity to find out about it. In fact, they

considered it necessary to come right out and talk to patients.

Many patients involved in sex work hide their identity because they worry

about how others see them; they know that not many in society accept them. However,

I do think that nurses need to know, so that the patients can be provided with the

appropriate care. Just be sensitive when talking to them, provide them with privacy,

and tell them directly that it is not because we are nosy that we ask these questions,

but because of our responsibilities as a nurse. (II-2, male nurse, social hygiene clinic,

34y)

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 Some nurses confessed that they hesitated to care for sex workers, because

they had to be careful to protect themselves against complaints. They would

approach these patients in a soft tone of voice and hide their facial expressions to

avoid misunderstandings. As one nurse commented:

Many of the suspected sex workers have threatened to report us to our

supervisor when they felt that they were being “discriminated” against. So we just

provide routine care without “seemingly” discriminating against them. (FGD1-1,

female general nurse, 33y)

Also, to protect patient confidentiality, nurses were not supposed to probe

into the nature of the patients‘ work, particularly if a patient was suspected to be a

sex worker. This was a sensitive matter, and talking about it would be regarded as

gossip, since a patient‘s work was unrelated to nursing care. A nursing clinical

instructor would discourage her students from exploring a patient‘s background.

A nursing student was very curious about a young patient with STD. I

cautioned the student to be sensitive to the confidentiality of personal data. We also

do not want to gossip about the personal life or work of the patients. (FGD1-2,

female general nurse, lecturer, 45y)

Sometimes, it was the infectious disease that caused nurses to hesitate to take

care of these clients, and not necessarily the fact that the patient was a sex worker. A

few nurses confessed that they would take excessive personal precautions against

infection when dealing with HIV patients, who so happened to be sex workers. There

was the subtle implication of discrimination from nurses towards sex workers

associated with a stigmatized disease such as HIV.

When I take care of patients with HIV, although I am not sure if they are sex

workers, I will use an extra layer of gloves and big eyeglasses, and be cautious

155
about handling bodily fluids in suspected cases to protect myself. I do struggle and

feel much tension when taking extraordinary precaution in executing this kind of

responsibility to care for these clients. (FGD2-4, female ICU nurse, 35y)

Even in a social hygiene clinic where sex workers sought health care, nurses

hesitated to care for clients suffering from STDs. A nurse recalled his early working

experience in a social hygiene clinic when he was young:

It was the norm to keep a distance from clients with STDs in the social

hygiene clinic, regardless of the job nature of the clients. (II-1, male nurse, social

hygiene clinic, 63y)

The attitude of nurses, the responses of the sex worker to the care that was

provided, the association of sex workers with detrimental infectious illnesses, and

organizational norms had contributed to the hesitation that nurses felt about caring

for sex workers. These influences, along with the general attitude of the nurses, the

self-stigma of the sex workers, disease-related issues, and social issues had created a

precarious dynamic in the nurse-patient relationship.

Theme 4: The preparations involved in caring for patients who might be involved in

sex work

Nurses often found that they had little time to attend to the psychosocial aspect of

caring for patients, and that it was even more difficult to provide such care when sex

workers hid their identity and were ―invisible‖ in health care settings.

I provide all patients with the treatments required according to protocol. But

if I know about the patients’ sex work, I can provide some health education on

protective sex, since they are a high-risk group. (FGD2-3, male nurse, general nurse,

34y)

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 When nurses were asked if they thought that special training was needed to

care for sex workers, their opinions were divided. A nurse teacher did not think that a

special curriculum on sex workers and stigmatization was needed.

There is no specific nursing curriculum focused on sex workers. I believe it is

more important to talk about equal treatment to all, instead of focusing on sex

workers. Everyone is the same. I think it would be stigmatizing if the topic of sex

workers were to be added to the nursing curriculum. (FGD5-1, female obstetrics &

gynecology nurse & sex therapist, lecturer, 44y)

A practicing nurse working in an outpatient clinic thought that it was more

important to emphasize communication skills in working with vulnerable or

marginalized populations.

There are courses regularly offered by hospitals, not focusing on sex workers,

but broadly on the skills for communicating with vulnerable or marginalized

populations and for handling complaints. It is important not to give the impression to

patients that we are discriminating against them. (FGD1-4, female GOPC nurse, 35y)

However, a psychiatric nurse reflected on her work before and after receiving

training specifically on caring for sex workers in hospitals and nurse clinics. She

highlighted the issue of patient-centered care and noted that nurses should update

their knowledge and skills to provide care to patients as individuals, so as to meet

their diverse health care needs.

When I was a nurse working in the hospital, I just provided patient care

according to routine. The course taught me that nurses should have a better

understanding of their clients and be able to recognize the multiple dimensions of

health and wellness. Now, working in the nurse clinic, I will spend time listening to

the concerns of clients, provide them with health education, and show them that I

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care. (II-3, mental health nurse & sex therapist, nurse clinic, 40y)

Others suggested that training would be needed only for nurses who came

into frequent contact with sex workers.

I don’t think it is necessary to provide specific training to all nurses, but it

would be good to offer courses to those who will come into frequent contact with sex

workers, so that they are prepared to care for this special group of clients. This

should include those working in psychiatric units, social hygiene clinics, and

obstetrics & gynaecology units. (II-1, male nurse, social hygiene clinic, 63y)

This theme identified the various opinions held by the nurses on the issue of

providing specific training on caring for sex workers. While the nursing curriculum

emphasized providing equal treatment to all patients, it rarely mentioned any specific

vulnerable and marginalized populations. The majority of the nurses did not agree on

the need to have specific training related to sex workers, since their focus was on the

treatment of diseases and the provision of nursing care. They also expressed the

opinion that this kind of training might have the opposite effect and stigmatize sex

workers. Such training was considered necessary only for those who worked in units

that had frequent encounters with sex workers.

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Table 9-1 Examples of meaning units, summarized meaning units, sub-themes and themes

Participants’ quotes Codes Sub-themes Themes

On one hand, I see sex workers as vulnerable people. (FGD1-5) vulnerable people Conflicting moral Theme 1: Generally
attitudes toward sex conflicting attitudes
But there was an incident when I first learned that a friend of shaming and blaming workers toward sex workers
mine was working in a nightclub as a prostitute – it just popped work
out of my mouth to ask why she wanted to do that kind of dirty
job. (FGD1-5)

When we learn of a patient with a confirmed diagnosis of HIV Sex worker = HIV Sex worker = HIV?
or who is referred to the social hygiene clinic, then we often
think that the person is likely to be a sex worker. (FGD1-4)

―sex workers might be less likely to contract HIV since they Sex worker ≠ HIV
were aware of the need to protect themselves‖ (II-2)

Sex work is a personal choice (FGD6-1, male nurse, 34y) Normalizing sex work Liberal vs.
conservative feminist
Sex work work as an act of male exploitation of women‘s Condemning sex work attitudes toward sex
bodies and were clearly opposed to sex work. work
We are to have the professional attitude to serve all without Equal treatment to all Code of ethics in Theme 2: The
considering their occupation. That’s the expectation of our nursing professional
nursing profession. (FGD1)
obligation to provide

159
Participants’ quotes Codes Sub-themes Themes

Generally speaking, nurses may try very hard to adhere to their Subconsciously Inner ambivalence care to all
professional code of ethics… But I doubt if nurses can really unequal treatment
provide equal care to all patients…many nurses kept a distance
from those they believed were sex workers when giving
penicillin injections. (II-1)
I don’t feel pity for those who choose to do this kind of work for Personal beliefs/values
easy and quick money and then contract STDs or HIV. I do feel Barriers to provided
reluctant to take care of them, but I cannot discriminate
non-judgmental care at
against them outwardly...(FGD1-3)
the intrapersonal
Although sometimes I would like to know more about these Lack of self-efficacy level
patients, I dare not ask because I am afraid that they might Theme 3:
think that I am being nosy or discriminating against them. Acknowledgment of
(FGD1-4) one‘s hesitation in
…I wanted to teach a teenage sex work about safe sex and Interaction, Barriers to provided caring for sex workers
condom use. She glanced at me and said offensively that it was characteristics of the non-judgmental care at
none of my business. Her rudeness made me angry...(FGD5-1) sex worker, diseases the interpersonal
level
It was the norm to keep a distance from clients with STDs in the Institutional values and Barriers to provided
social hygiene clinic, regardless of the job nature of the clients. norms, time constraints non-judgmental care at
(II-1) the institutional level

I believe it is more important to talk about equal treatment to Against sex work- Satisfied with the Theme 4: The
all, instead of focusing on sex workers. (FGD5-1) related training current curriculum of preparations involved
caring vulnerable in caring for patients
groups – formal who might be

160
Participants’ quotes Codes Sub-themes Themes

curriculum involved in sex work

I don’t think it is necessary to provide specific training to all Agree on sex work- Call for broad and
nurses, but it would be good to offer courses to those who will related training sensitive nursing care
come into frequent contact with sex workers…(II-1)

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9.2. Discussion

This is the first study to explore the attitudes of nurses toward caring for sex workers

in Hong Kong. This qualitative study provides a preliminary understanding of nurses‘

perspectives on sex workers. The findings of this study highlight key issues that

nurses should be aware of in caring for sex workers, namely: the intertwining of

personal and professional attitudes in nurses; differences in attitudes toward sex

workers across nursing specialties; and the use of a socio-ecological model for

understanding the attitudes and practices of nurses in caring for sex workers.

The intertwining of personal and professional attitudes

The topic of sex workers is controversial, and heated discussions took place among

the nurse participants, but no consensus on personal attitudes toward sex workers

could be reached. Similar to the findings of a review of various stakeholders, in

which diverse opinions on sex workers were expressed (Ma, Chan, & Loke, 2018b),

nurses in Hong Kong held conflicting, inconsistent, and ambivalent personal feelings

towards sex workers. However, it was encouraging to find that all of the nurses who

were interviewed understood their professional nursing code of ethics and conceded

that they were obligated to provide equal care to all patients, including sex workers.

As personal and professional attitudes are intertwined and inseparable (Pipes,

Holstein, & Aguirre, 2005), the conflicting values could be found in the way in

which they described their personal attitudes and willingness to care for sex workers.

For example, nurses claimed that they would provide ―sensitive‖ care when they

perceived sex workers as ―self-stigmatized,‖ and that they would ―keep a distance‖

when they viewed sex workers as ―immoral‖ or ―diseased.‖ This finding is supported

by the findings of other studies on the personal and professional attitudes of health

162
care providers (Dorsen & Van Devanter, 2016; Paprocki, 2014; Rabow, Remen,

Parmelee, & Inui, 2010), which indicated that the inner struggles and tensions of

nurses, and their hesitation to care for sex workers, might have an impact on their

nursing care.

It is worth noting the potential discrepancy between the personal expectations

and actual practice of the nurses. The conflict between their personal beliefs and

professional ethics may cause inner discomfort and dilemmas, lead to hesitation, and

subsequently have a negative impact on clinical practices (Paprocki, 2014). The

implicit or explicit bias of nurses toward sex workers may prevent sex workers from

receiving optimal care, resulting in health disparities. Nurses should reflect on their

personal values and professional ethics, and examine their hesitation and clinical

practices to ensure that they are providing the best care for their patients, including

sex workers.

Differences in attitudes toward sex workers across nursing specialties

The findings from this study show that there are differences in the attitudes of nurses

toward sex workers across the nursing specialties. A nurse‘s specialties, clinical

experience, and training contribute to his/her ease, confidence, and willingness to

care for sex workers. Generally speaking, among the nurses who were interviewed,

those who worked in a social hygiene clinic, obstetrics & gynecology unit, and

psychiatric unit were more willing and ready to talk with clients who were sex

workers and more likely to try to understand them. These nurses were also those who

considered it necessary to receive specific training to care for sex workers.

By the nature of their work, sex workers are at risk of developing sexual and

reproductive health problems and mental disorders (Ross et al., 2012). As such,

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nurses working in a social hygiene clinic, an obstetrics & gynecology unit, or a

psychiatric unit have a greater chance of coming into contact with sex workers.

Nurses from these departments were more likely to attend special training courses

related to caring for sex workers at their workplaces. The specific training helped

these nurses by improving their knowledge, communication skills, intention and

willingness to care, and sensitivity to the psychosocial needs of sex workers.

The socio-ecological model for understanding the attitudes and practices of nurses

in caring for sex workers

To better understand the personal attitudes and professional practices of nurses in

caring for sex workers, a conceptual framework based on a socio-ecological model

(SEM-NrSw) is proposed. The following multilevel factors are dynamic influences

on the attitudes and clinical practices of nurses when caring for sex workers:

intrapersonal (nurse), interpersonal (interaction with sex workers), institutional

(organization and health care settings), and community (social and cultural).

At the intrapersonal level, the personal values, clinical speciality, and training

received by the nurses affected their professional practices. It has been suggested

that professional practices are influenced by deep-rooted personal values, which are

formed by the community, social and cultural background, and work organization of

the nurses (Goslin, 1969; Poorchangizi, Farokhzadian, Abbaszadeh, Mirzaee, &

Borhani, 2017). At the interpersonal level, the impression/appearance of sex workers,

their perceived self-stigma, the stigmatized diseases contracted by sex workers, and

the dynamic interaction between nurses and sex workers, can also be influential, and

should not be neglected.

At the institutional/organizational level, the professional code of ethics and

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conduct, clinical norms and regulations, types of clinical specialties and

environments, and the offer of training programs could also shape the professional

values, attitudes, and practices of nurses.

At the community level, the established social and cultural positions that

marginalize and stigmatize sex workers as immoral, deviant, and deserving of

punishment have an impact on the attitudes and clinical practices of nurses (Shannon

et al., 2015; World Health Organization, 2005). Selling one‘s body is still

unacceptable in Chinese societies, and Hong Kong is no exception. Such a cultural

position makes an open discussion on caring for sex workers difficult to conduct

among nurses in health care settings.

The proposed conceptual framework (SEM-NrSw) makes the complexities of

the determinants of nurses‘ attitudes and practices in caring for sex workers easier to

understand. It can also be adopted as a guideline to inform the development of

educational or intervention programs aimed at promoting high-quality services for

sex workers delivered with sensitivity.

9.3. Implications

Everyone deserves to receive high-quality health services delivered in a respectful

manner. In order to create a non-judgmental and friendly health care environment for

sex workers, nurses need to be aware of their personal attitudes, and to comply with

the profession‘s obligations when providing care to sex workers and other

marginalized groups. The provision of education and intervention programs is

recommended to address the influence of personal values and beliefs on nursing

practices. The proposed conceptual framework (SEM-NrSw) highlights the

opportunities for interventions to be delivered at different levels to increase the

165
quality of the care provided to sex workers.

At the individual level, it is important for nurses to recognize their deep-

rooted personal values and beliefs towards sex workers, and to reflect upon and

scrutinize their professional practices (Eng & Pai, 2015; Joyce-McCoach & Smith,

2016; Sandars, 2009). Nurses should understand their stereotyping attitudes and be

aware of potential biases that may lead to health disparities in marginalized

populations.

At the organizational level, educational or training courses are recommended

to enhance nurses‘ understanding of sex workers. Such programs are particularly

important for nurses working in psychiatric units, obstetrics & gynecology units, and

social hygiene clinics.

The intergroup contact hypothesis developed by Allport et al. (1954) (Allport

et al., 1954) suggests that intergroup contact can reduce prejudice and increase

harmony between different groups. A study adopting this hypothesis was conducted

by bringing together medical students and sex workers (Robitz et al., 2015). The

study demonstrated the effectiveness of this approach in increasing empathy and

decreasing stigma among medical students towards sex workers, as well as in

empowering sex workers by making them more likely to seek health care and to

make their opinions known. Therefore, training programs or workshops, aimed at

enhancing mutual understanding through the exchange of views and experiences,

have the potential to reduce stigma towards sex workers and increase the sensitivity

of the care delivered by nurses. It will also remove one barrier to the seeking of

health care by sex workers.

Finally, at the social and cultural level, the promotion of global health and

human rights can be a strategy to lessen public stigma, discrimination, exploitation

166
and violence against sex workers, and to strengthen the human right to equal access

to health care services (Amnesty International, 2015; Decker et al., 2015). Although

a review of the literature did not find a consensus among various stakeholders on

attitudes toward the legal status of sex workers (Ma et al., 2018b), it is paramount to

call for an open discussion and for the formulation of laws and regulations on the

human right of sex workers to health care.

Limitations

There are several limitations in this qualitative study. First, there is a possibility that

socially desirable responses were provided by the interviewed nurses on this

sensitive topic. Although the interviewer emphasized her non-judgmental attitude at

the beginning of each interview, and assured the participants of confidentiality, nurse

interviewees who held negative personal attitudes might have been reluctant to

express their true feelings, and hence provided politically or professionally correct

answers. The findings from the interviews should be interpreted with caution.

Second, the results of the study may not be generalized. The recruitment of

the participants was based on convenience and snowball sampling, and over 40% of

the participants were recruited from among practicing nurses studying for their

master‘s or doctoral degree in one of the universities in Hong Kong. Nevertheless,

these nurses were working in a variety of health care settings and geographic

locations, and represent the oices of nurses in Hong Kong.

Third, the majority of the participants only expressed their attitude towards

and their care for patients who had been diagnosed with HIV or STDs, and whom

they suspected to be sex workers. Future studies should consider recruiting only

those nurses who have experience of providing services to sex workers.

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9.4. Conclusion

Given that sex-related topics are still a taboo in Chinese communities, the health

needs and stigmatization of sex workers are not topics that have been included in

nursing education and clinical practices in Hong Kong. Nurses have had few

opportunities to talk about sexual health or sex-related topics. This study already

triggered much heated discussion among the nursing students in the study setting.

This study found that nurses held strong, but ambivalent, personal attitudes

toward sex workers, but will comply with the professional code of ethics in

providing care to patients whom they suspect to be sex workers. It is essential that

nurses promote a safe and non-judgmental environment when providing health

services, to ensure that all, including sex workers, have equal access to health care.

In a review of the literature on what affects usage of health care services by

sex workers, the socio-ecological model was also used as a tool to understand the

barriers and facilitators to the accessing of health services by sex workers (Ma, Chan,

& Loke, 2017). The modified socio-ecological model (SEM-NrSw) in this study can

inform education or training programs to enhance the self-reflection of nurses and

the provision of quality of care for sex workers. The intergroup contact hypothesis

approach intervention may be considered to reduce prejudice and increase harmony

between nurses and sex workers.

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 Chapter 10

STUDY II A qualitative study into female sex workers’ experience of stigma in

the health care setting in Hong Kong

[Link]

10.1.1. Study participants

10.1.2. Health conditions and accessing health care services

10.1.3. Themes of the study

[Link]

[Link]

[Link]

*Content of this chapter is published (partial content included in this chapter):

Ma, H., & Loke, A. Y. (2019). A qualitative study into female sex workers‘

experience of stigma in the health care setting in Hong Kong. International journal

for equity in health, 18(1), 175.

169
In phase two, 22 semi-structured individual interviews were conducted with FSWs

from December 2018 to February 2019. The interview was conducted by a research

student at the office of one of the NGOs or at one-woman brothels accompanied by

an NGO staff member. The interviews lasted from 42 to 124 minutes. The interview

data were transcribed and briefly analyzed within one week after the holding of the

interview. Data saturation was reached when 18 interviews had been completed.

Four additional interviews were conducted to ensure that no new information would

be generated.

10.1 Results

10.1.1. Characteristics of the participants

The participants were recruited from various settings with the assistance of the

NGOs. They included those who work in one-woman brothels (n=18), massage

parlors (n=3), and those who are involved in compensated dating (n=1). The

participants were 30 to 59 years of age. The majority of the FSWs were born in

mainland China (n=20), one was born in Hong Kong, and another in Vietnam. They

had lived in Hong Kong from two to 20 years. Approximately half of them (n=10)

had received a primary school education, while the rest had received a middle school

education (n=12). All but one of them had had an unsuccessful marriage: two had

separated from their spouse and 19 had divorced, with six of them having remarried.

All but three of the participants had children, and 10 had had at least one induced

abortion. The majority of them lived in government-subsidized public housing (n=8)

or in a rented apartment (n=8), two lived in a private apartment, and four lived and

worked in a rented one-woman brothel.

All the participants engaged in the sex industry for money and viewed sex

170
work as a rational choice. The reasons were complex, and many factors were

interrelated. The majority of the divorced women (n=15) were confronted with great

economic difficulties and viewed sex work as a means of survival, such as the

responsibility of raising children, rent house, and live independently. Over half of the

participants (n=14) reported a lack of job opportunities. Nine of them complained

about the low-paid labor work in the service industry, four reported limited job

opportunities due to their health condition, and one could not speak the local

language fluently. Besides, three participants needed to pay off the family debt. Only

one sex workers worked for buying luxury goods.

The participants had been engaged in sex work for an average of 3.95 years

(range 0.5-12 years), and were serving about 2 to 7 clients a day. Their monthly

income ranged from HKD$4,000 to HKD$100,000 (US$510-$12,800). Five of them

had sources of income other than that derived from sex work.

In relation to self-protection in sex work, all except three of the participants

used a condom consistently with their clients. However, two of them had had a

condom slip off or removed by the client during intercourse, and 14 provided

unprotected oral sex. All denied ever having engaged in anal sex.

10.1.2. Health conditions and accessing health care services

The participants engaged in various types of health risk behaviours, such as smoking

(n=10), drinking alcohol (n=5), gambling (n=3), being shopaholics (n=2), and using

illicit drugs (n=1).

The participants suffered from a range of diseases. STDs were the most

frequently reported forms of disease, with urethritis being the most common (n=10),

followed by vaginitis (n=5), chlamydia (n=2), syphilis (n=1), hepatitis B (n=1),

171
herpes (n=1), and acute pelvic inflammatory disease (n=1). The participants also

suffered from chronic conditions, including hyperthyroidism (n=2), hypoglycemia

(n=2), diabetes (n=1), heart disease (n=1), stomach ulcers (n=1), endometrial polyps

(n=1), headache (n=1), back pain (n=1), and plantar fasciitis (n=1). (See Table 10-1)

All but two participants had ever sought health services in the past year

(n=19). The most common reasons for seeking help were for HIV/STDs tests or

treatments (n=15), followed by an annual health check-up (n=6) and for the

management of chronic diseases (n=3).

The participants tended to seek health care from NGOs (n=10), followed by

social hygiene clinics (n=7) and private doctors (n=6). The participants had

reservations about seeking health services from public hospitals in Hong Kong.

Among those who sought such services, four did so when they returned to mainland

China and one when she returned to Vietnam; only three were willing to do so in

Hong Kong. (See Table 10-2).

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Table 10-1 Characteristics of the female sex workers (FSWs) and their sex work

Personal information Description N (%)

Age (years) 30-59 41.14
(SD=6.81)
Place of origin Hong Kong 1 (0.05)
Mainland China 20 (90.91)
Vietnam 1 (0.05)
Duration of residence in Hong Kong 2-20 years 10.43
(for non-locals) (SD=6.14)
Educational level Primary school 10 (45.45)
Junior middle school 7 (31.82)
Senior middle school 5 (22.73)
Marital status Married 1 (0.05)
Remarried 6 (27.23)
Divorced 13 (59.09)
Separated 2 (0.09)
Had at least one abortion 10 (45.45)
Has children 19 (86.36)
Type of housing Private apartment 2 (0.09)
Public housing 8 (36.36)
Rental apartment 8 (36.36)
Brothels 4 (18.18)
Sex work
Reasons for practicing sex work Economic difficulties 22 (100.00)
Personal monthly income (HKD)
Work mode Full-time 20 (90.91)
Part-time 2 (0.09)
Working venue One-woman brothel 18 (81.82)
Massage parlor 3 (13.64)
Hotel 1 (0.05)
Years in sex trade (years) 0.5-12 3.95 (SD=2.98)
Average number of clients per day 2-7

Monthly income from sex trade (HKD) 4,000-100,000 36,789

(SD=22700)
Other sources of income aside from sex 5 (22.7)
work
Unprotected sex with clients
Vaginal sex 1 (0.05)
Ineffective use of condom 2 (0.09)
(slippage during intercourse
or removal of condom)
Oral sex 14 (63.64)
Anal sex 0 (0.00)
SD: Standard deviation

173
Table 10-2 Health status of the female sex workers and their utilization of health

care services

Variable N (%)
Health status
Sexually transmitted diseases
Syphilis 1 (0.05)
Chlamydia infection 2 (0.09)
Hepatitis B 1 (0.05)
Herpes 1 (0.05)
Vaginitis 5 (22.73)
Urethritis 10 (45.45)
Other diseases
Acute pelvic inflammatory 1 (0.05)
disease
Hyperthyroidism 2 (0.09)
Hypoglycaemia 2 (0.09)
Diabetes 1 (0.05)
Heart disease 1 (0.05)
Stomach ulcers 1 (0.05)
Endometrial polyps 1 (0.05)
Addictions
Smoking 1-30 cigarettes/day 10 (45.45)
Drinking 5 (22.73)
Gambling 3 (13.64)
Shopaholic 2 (0.09)
Drugs 1 (0.05)
Health care service experience
Had made use of health care services in the past year 19 (86.36)
Reasons for using the health care services
Medical consultation/advice 6 (27.27)
HIV/STD testing and treatment 15 (68.18)
Chronic disease management 3 (13.64)
Health care services sought
STDs clinic (Social hygiene clinic) 7 (31.82)
Private health sector 6 (27.27)
The non-governmental organization 10 (45.45)
Public hospital in Hong Kong 3 (13.64)
Public hospital in mainland China 4 (18.18)
Public hospital in Vietnam 1 (0.05)

10.1.3. Themes of the study

The interview data can be grouped into three themes: experience of stigma in the

health care setting; coping with the stigma of sex work; and the call for non-

judgmental holistic health care. Examples of meaning units, summarized meaning

units, sub-themes and themes are presented in Table 10-3.

174
Theme 1: Experience of stigma in the health care setting

The experience of stigma and discrimination among FSWs who accessed healthcare

services varied. We found that 12 out of the 22 participants indicated that they did

not experience discrimination from the health care providers. Despite the long

waiting time at the public health sectors, some commented favorably about the

universal coverage of the health care services in Hong Kong. In fact, the majority of

the participants did not perceive the bad attitude of the health care providers as a sign

of stigma when seeking treatment. Instead, they perceived all patients were treated

equally, or treated with equally bad attitudes.

By contrast, some FSWs had experienced stigmatized attitudes from health

care providers when they sought treatment for their STDs. The participants believed

that the stereotypes held by health care providers were that women who contracted

STDs were sex workers and fallen women. They may experience, anticipated, or

internalize stigma when accessing health care services.

Experienced stigma

The participants complained that health care providers, especially those from the

public health sector, hold negative and discriminatory attitudes towards them. A

participant described her unfortunate experience at a social hygiene clinic.

I visited a social hygiene clinic three years ago. The staff there probably

suspected that I was a sex worker, because they were rude and spoke to me in harsh

reprimanding voices. I felt humiliated. I definitely won’t go there again. (#5)

Anticipated stigma

The FSWs believed the health care providers held prejudiced attitudes toward sex

175
work and STDs, and would judge them as sinful and diseased. Being worried about

and anticipating or having experienced disdain from health care providers, FSWs

accentuated their self-stigma when they were forced to access to health services for

STDs:

I was so scared and worried about being humiliated when I first sought help

for STDs. I wore a mask and big sunglasses when I visited the clinic. As soon as I

had completed my medical consultation, I ran away like “a rat scampering in the

street.” (#12)

Internalized stigma

The experienced stigma and the anticipated stigma could lead FSWs to internalize

the prejudice, manifesting in shame, fear, and low self-esteem. The majority of the

FSWs felt ashamed of their occupation. They feared that their identity as a sex

worker might be revealed in the process of visiting STDs clinics, and were worried

about the consequence of being identified as a sex worker, such as gossip and

discriminated by the health care providers.

I felt ashamed of myself when I visited the social hygiene clinic. A good

woman does not need to have the STDs examination. The health care providers must

associate me with a sex worker and a dirty woman. They must look down on me. (#5)

The FSWs believed the general public, including their ―sex customers,‖ held

prejudiced attitudes toward sex work and STDs. They would feel ashamed if they

were witnessed visiting the public STDs clinic.

It would be embarrassing to bump into acquaintances at the social hygiene

clinics. I won’t seek help from public health services or social hygiene clinics. (#11)

In summary, FSWs acknowledged that the sex trade and STDs were socially

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despised. They had experienced or anticipated stigma and discrimination in the

health care setting. In addition to the stigma associated with sex work and STD, the

new immigrants may encounter more prejudice and expect a different treatment from

the health care providers. The perceived lack of public acceptance when they sought

help at health services clinics for STDs led to a feeling of stress, fear, and shame.

Theme 2: Coping with the stigma of sex work

The participants adopted various strategies to cope with the stigma associated with

sex work and STDs in the health care setting. Those who accepted the social stigma

of sex work may adopt passive coping strategies, including the concealment of sex

worker identity, avoidance of stigmatizing situations, ignore the stigma. FSWs who

resisted the social stigma of sex work may adopt active coping strategies, including

selective disclosure of sex worker identity, justification of sex work, seek out social

support. Below is a description of the coping strategies.

Passive coping

Concealment of sex worker identity

The majority of the participants worried that if they disclosed their sex work they

would be inviting moral judgments from health care providers and gossip about their

identity, leading to shame and embarrassment as well as possibly impacting the care

that they would receive. Thus, the majority would attempt to protect their privacy

when seeking health care services. For example:

I will lose face if I disclose my sex worker identity to the health care provider.

It is an untold secret. (#1)

Some would lie about their work. For example, one participant commented:

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 I can be a housewife or a manager in a company. It is not necessary to tell

health care workers the truth about my work when seeing a doctor. Even if I get HIV,

it does not mean that I necessarily got it from my sex work. Everyone has a chance to

become infected. (#13)

Sex work is a taboo in the health care setting, and most of the FSWs were

aware that health care providers in Hong Kong are not allowed to directly ask them

this sensitive question. One FSW described how a doctor asked her about her sexual

activities:

Once I went to a clinic for STDs or gynaecological diseases, and I could tell

that the doctor there suspected me of engaging in sex work, but he knew that it would

be offensive if he asked directly. Instead, he asked me whether or not I use a condom

with my partner and whether or not I have a job. (#19)

Avoidance of stigmatizing situations

Some FSWs believed the health care providers, especially those from the public

health sectors, held prejudiced attitudes toward sex work and STDs. To avoid

situations that may result in stigma and discrimination, many FSWs preferred to use

clinics operated by NGOs, where they could receive both informational and

emotional support and enjoyed free condoms and sexual and reproductive health care

services. They did not have to worry about disclosing their sex work to the NGOs

since the service was anonymous.

I would go to the local NGOs for regular STDs tests. Because it is a sex

worker-friendly organization, I feel safe and be respected there. (#4)

To avoid being identified as a sex worker, some FSWs would visit a hospital

of the neighbouring city or their hometown in mainland China. Moreover, they

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commented that the service in mainland China was more convenient and

comprehensive, and they did not to feel embarrassed since they could avoid talking

about STDs.

If I want to get sexual health check-up, I can go to the department of

obstetrics and gynaecological department instead of the STDs clinics. No one will

associate me with a sex worker there. Also, I could have a full body check-up without

mentioning STDs tests. (#7)

Ignore the stigma

Ignore the attitudes of the health care providers was considered as an important

strategy to buffer against the stress and fear when accessing health care services.

Many participants built resilience and had learnt to ignore others‘ perception. As one

participant explained:

I understand that not everyone accepts sex workers. Therefore, I pay more

attention to the disease treatment than the attitudes of the health care provider. Their

perception of me would not affect my life. (#3)

Active coping

Selective disclosure of sex worker identity

FSWs would weigh the risks and benefits of revealing their identity. Sometimes, the

perceived benefits of revealing the truth to receive appropriate and timely diagnostic

tests and medical treatment might trigger the decision to make the disclosure.

We could receive more comprehensive and necessary diagnostic tests and

treatments if we disclose our sex work at the social hygiene clinic. Besides blood

tests, they also offer a saliva test and a Pap smear test. (#12)

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 When a serious illness such as HIV is suspected, it is better for us to disclose

our sex work because it is important information that will help the doctors and

nurses to decide on the diagnostic tests and treatment plan. Only if we tell the truth

can we get prompt treatment. (#9)

The participants also commented on the supportive health care environment

that empowered them to be open. The participants were confident about the

maintenance of confidentiality in the public and private health sectors, and therefore

did not see the need to conceal their identity from the health care providers.

There was a gradual change in FSWs‘ attitudes toward STD services. Several

FSWs admitted that they felt embarrassed and ashamed to have STDs tests when

they entered into the sex industry, and were reluctant to reveal their identity to the

health care providers at the social hygiene clinic. Only after they became acquainted

with them and had established mutual trust were they able to disclose their sex work.

They observed that the attitudes of the health care providers did not change after they

disclosed their secret.

The attitude of the health care professionals in the social hygiene clinic did

not change after I disclosed my sex work. The nurse was gentle when she was

examining me. She also spoke softly, telling me to “Relax, relax!” (#15)

Justification of sex work

In most circumstances, FSWs resisted the stereotype that sex work was immoral or

deviant. They tended to justify sex work as a personal and rational choice, and were

not ashamed of engaging in it. They felt that, as divorced women, single mothers,

and lacking in education and other skills, they had limited job opportunities and

choices. They confided that sex work offers economic benefits, flexible work hours,

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and allows them to provide their family with the necessities of life. As an FSW

commented:

Women engage in sex work for various reasons, many FSWs scarify their

pride and dignity for their family. I need to pay for the rent, the tuition fee of my son,

and the living expenses. Sex work is the only way for me to make a living and be a

responsible mother. The health care providers should not judge me based on the sex

work I do. (#20)

Some even suggested that their work could reduce the incidence of rape for

the public good. These FSWs justified their sex work as labor they undertook to

support their family and felt empowered to disclose their identity to health care

providers. For example:

The attitudes of the health care provider won’t upset me. I have no other

choice, and I am proud that I can make a living for myself. I also think that sex

workers have helped to reduce the incidence of rape and the crime rate. (#16)

The participants also emphasized that in Hong Kong, commercial sexual

services between two adults was not illegal, and being an FSW was not illegal as

long as one serves in a one-woman brothel and was legally resident in Hong Kong.

The participants were free from the fear of being arrested even if they disclosed their

work.

Seek out social support

Social support played a vital role in reducing the fears and stress of FSWs. Many

participants were accompanied by peers or staff of NGOs during their visit to doctors.

The emotional support and the resilience of peers who against the stigma of sex work

helped to reduce their psychological stress. An FSW commented:

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 My peers gave me great support. They encouraged me to have routine STDs

tests and even accompanied me to the hospitals. This makes me feel less stressed

when visiting the doctor. (#12)

In summary, the interviewed FSWs adopted various strategies to combat

stigma in the health care setting. The majority of the FSWs chose to hide their

identity due to the fear of stigma. Those who were able to disclose their identity were

empowered by their open-minded attitude towards sex work, the perceived benefits

of disclosing their identity, and the perception of a supportive health care

environment. Sometimes, FSWs would ignore the attitudes of the health care

providers or sought help from the place where they felt safe and friendly. Some

FSWs tended to justify sex work and emphasize their contribution to their family and

the society. Moreover, the social support they received allowed them to deal with the

stress and fear when accessing health care services.

Theme 3: The call for non-judgmental holistic health care

The majority of the participants believed they would more readily access to health

services if the health care team had a good understanding of the sex industry,

recognized them as people, and treated them holistically with dignity. Besides sexual

health, they desired comprehensive and holistic health care which could take into

consideration of their multiple health care needs, such as mental disorders, diabetes,

hypoglycemia, insomnia, plantar fasciitis, problem gambling, and other addictions.

“Our comprehensive health care needs should be addressed. For example,

my heel is killing me, and I could not walk a long distance. However, I have no idea

where to seek help. I wish someone could help me with these problems other than

STDs.” (#15)

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Multiple health care needs beside STDs

Due to life difficulties/traumas and the stigma associated with sex work and STDs,

many participants had developed mental health problems, such as severe stress,

anxiety, insomnia, and depression, and some had even attempted suicide. Several

participants engaged in various types of addiction to cope with the difficulties of

their lives and with emotional disorders, including chain smoking, drinking alcohol,

binge drinking, shopping, taking drugs, and gambling. All except one did not seek

mental health care services. The one person who had visited a mental health care

provider was merely told ―not to think too much.‖ She then drank a great deal of

alcohol to deal with her depression and sadness.

When I feel sad or unhappy, I will go out with friends and drown my sorrows

with alcohol. (#17)

Another FSW who suffered from a gambling addiction described her

emotional despair:

I am a gambler! That way I can free myself from thinking of my troubles. But

once I lost a huge amount of money in a casino. I hated myself so much and

attempted to commit suicide with a knife. Eventually, I called the police for help.

(#15)

Expand the scope of services

FSWs with multiple health care needs made a strong call for the provision of non-

judgmental holistic care. Some participants highlighted the needs of the health care

providers to understand the sex industry and their occupational health and safety.

Only if health care providers have a good understanding of the sex industry

and our work environment would they understand our occupational risks and be

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more sensitive to our multiple health care needs. They would also understand our

fears, sorrows, and depression beyond those related to the contraction of STDs. (#14)

Further, some FSWs spoke very favorably of the free sexual services

provided by the social hygiene clinic and the NGOs, especially the non-judgmental

care and outreach services provided by the NGOs. However, they also highlighted

that the services provided by these organizations were not comprehensive enough,

and they made a series of recommendation for the expansion of health services. For

example:

Sometimes, I feel depressed. But I never seek help from a health professional

because I can neither afford the years-long waiting time at the public health sector

nor afford the expenses in the private health sector. Since we have regular STDs

screening tests at the NGOs or the social hygiene clinic, it would be great if they

could offer more supportive services, like psychological counselling or referral to

mental health treatment. (#15)

This theme revealed that besides STDs, FSWs had multiple health care needs.

They were also at risk of developing mental disorders and addictions as a result of

social stigma and life difficulties. STD clinics or NGOs should take a holistic

approach that considers multiple health care needs when caring for FSWs.

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Table 10-3 Examples of meaning units, summarized meaning units, sub-theme and theme

Meaning unit Summarized meaning Sub-theme Theme

unit
I visited a social hygiene clinic three years ago. The Negative experience Experienced stigma Experience of stigma
staff there probably suspected that I was a sex worker, in the health care
because they were rude and spoke to me in harsh setting
reprimanding voices. I felt humiliated. I definitely won’t
go there again.
I was so scared and worried about being humiliated Worried about being Anticipated stigma
when I first sought help for STDs. I wore a mask and big humiliated
sunglasses when I visited the clinic. As soon as I had
completed my medical consultation, I ran away like “a
rat scampering in the street.
It would be embarrassing to bump into acquaintances at Being witnessed in the Internalized stigma
the social hygiene clinics. I won’t seek help from public public health sector cause
health services or social hygiene clinics. stress
I can be a housewife or a manager in a company. It is Hide private information Concealment of sex Coping with the
not necessary to tell health care workers the truth about and to set boundaries worker identity stigma of sex work
my work when seeing a doctor. Even if I get HIV, it does with health care
not mean that I necessarily got it from my sex work. providers
Everyone has a chance to become infected.
I would go to the local NGOs for regular STDs tests. Choose stigma-free Avoidance of
Because it is a sex worker-friendly organization, I feel alternative services stigmatizing
safe and be respected there. situations
I understand that not everyone accept sex workers. Normalize others‘ Ignore the stigma
Therefore, I pay more attention to the disease treatment negative attitudes
than the attitudes of the health care provider. Their
perception of me would not affect my life
We could receive more comprehensive and necessary Analyze the risks and Selective

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Meaning unit Summarized meaning Sub-theme Theme
unit
diagnostic tests and treatments if we disclose our sex benefits disclosure of sex
work at the social hygiene clinic. Besides blood tests, worker identity
they also offer a saliva test and a Pap smear test
Women engage in sex work for various reasons, many Use poverty as an excuse Justification of sex
FSWs scarify their pride and dignity for their family. I of sex work work
need to pay for the rent, the tuition fee of my son, and
the living expenses. Sex work is the only way for me to
make a living and be a responsible mother. The health
care providers could not imagine how difficult for a
single mother living in Hong Kong. They should not
judge me based on the sex work I do
My peers gave me great support. They encouraged me Handle stress with social Seek out social
to have routine STDs tests and even accompanied me to support networks support
the hospitals. This makes me feel less stressed when
visiting the doctor.
When I feel sad or unhappy, I will go out with friends Understand the complex Multiple health The call for non-
and drown my sorrows with alcohol. needs care needs beside judgmental holistic
STDs health care

Only if health care providers have a good understanding Suggest for better health Expand the scope
of the sex industry and our work environment would care services of services
they understand our occupational risks and be more
sensitive to our multiple health care needs. They would
also understand our fears, sorrows, and depression
beyond those related to the contraction of STDs.

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10.2. Discussion

The study aimed to investigate the experience of stigma in the health care setting and

stigma coping strategies among the FSWs in Hong Kong. Generally speaking,

stigma was not viewed as a concern for some FSWs unless they sought for STDs

services from the public STDs clinic. The participants believed that the stereotypes

held by the health care providers were that women who contracted STDs were sex

workers. The finding of this study is consistent with literature showing that, for

FSWs, stigma is an important issue when accessing of HIV/STDs health care

services (Beattie et al., 2012; Mtetwa et al., 2013; Scorgie et al., 2013). Despite the

available, accessible, and affordable public health care services in Hong Kong (Kong

et al., 2015), being a sex worker or having STDs is not socially acceptable and

sometimes a significant concern for FSWs when seeking help from the health care

providers.

The results revealed the flexibility of FSWs in responding to the stigma of

sex work and associated STDs in the health care setting. Their choice of stigma

coping strategies varied as a result of the self-perception, the perception of the

occupation, the perception of STDs and the severity of the disease, the perceived

risks and benefits, the complex interactions with the health care providers, and the

availability of the social supports. This finding provides insights into FSWs‘ internal

dilemma, on making a decision whether or not to disclose their identity. Consistent

with reports in the literature that FSWs rarely reveal their sex worker identity when

seeking professional help (Ndung'u, 2016; Urada & Simmons, 2014), the paradox of

coming out as a ―sex worker‖ was considered as most challenging for the majority of

the FSWs in this study. However, holding back one‘s feelings and emotions could

lead to stress and subsequent physical health problems (Paxton, 2002). The burden of

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internalized stigma and perceived stigma from the public and health professionals

could lead to a vicious cycle of internalized stigma, poor self-esteem, and illness.

It was quite encouraging to notice that a few participants were empowered to

open themselves up to face the stigma in society. The perceived seriousness of their

health condition and the potential benefits of disclosing their identity may cause

them to feel a pressing need to respond to their health problems and prompt them to

disclose their private information to the health care providers. Such disclosure often

invited more support from the health care providers, such as comprehensive and

timely diagnostic tests and treatments, empathetic, respectful, and non-judgmental

care, and free resources and services. Meanwhile, findings from this study further

indicated that the support in the health care setting facilitated FSWs‘ access to health

care services and the disclosure of private information. Similar findings have been

reported in other countries that indicated the disclosure of sex work could lead to

increased social support and vice versa (Benoit et al., 2018). Thus, it is crucial to

raise the awareness of health care providers that their support could help to end the

vicious cycle of stigma and illness among FSWs. The provision of a friendly

environment offering non-judgmental health services could help to mitigate the

stigma felt by FSWs and encourage them to access the services. The sexual and

reproductive health service provided by NGOs was considered to be friendly and

sensitive, which facilitates the provision of better services and bolsters the service

uptake rate.

In addition, results from the study highlight the need to address the multiple

health needs of the FSWs. Besides STDs, FSWs also need support for other

conditions, such as mental illness and addictions. However, they are facing barriers

to access specialty care which could have a significant impact on their health. As

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many of the FSWs have regular STDs check-ups, the health care providers of the

STDs clinics and NGOs should be sensitive to the needs of FSWs and offer referral

to those who need specialty care. Besides, it is suggested that a multidisciplinary

team may be considered to integrate mental health services and addiction with STDs

services.

10.3. Implications

The stigma of sex worker and associated STD may influence the experience of

health care services among FSWs, especially the experience of STDs services. In

order to improve the FSWs‘ experience of health care, interventions programmes

could be conducted at different levels.

At the individual level, interventions are needed to reduce FSWs‘ internalized

stigma According to the social identity theory (Tajfel, Turner, Austin, & Worchel,

1979), identity management strategies may help members of the stigmatized group

cope with stigma, restore their positive social identity, and improve the self-esteem.

Regarding various coping strategies FSWs may adopt, researchers are suggested to

take into the perspectives of the FSWs and find the fit identity management strategy

in which FSWs feel comfortable. Also, self-stigma reduction interventions among

people with other stigmatized conditions could be used as a reference to develop the

intervention to reduce the self-stigma among the sex workers, such as

psychoeducation, cognitive restructuring, and narrative intervention (Ma, Chan, &

Loke, 2018a; Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015).

At the instructional level, it is crucial to raise the health care providers‘

awareness of the stigma or subconscious bias toward FSWs. Health care providers

and students in the health care professions should participate in sensitivity-training

189
programs. These could focus on increasing their awareness and understanding of the

sex industry, increasing their knowledge about the multiple health risks and health

care needs of FSWs, and improving their history-taking skills and their ability to

encourage FSWs to disclose their health concerns, and instructing them on how to

promote a friendly and non-judgmental medical environment. The intergroup contact

theory suggested that the intergroup contact under the conditions of equal status,

common goals, intergroup cooperation, and institutional support could reduce the

bias and improve understanding (Allport et al., 1954). This approach may be used to

reduce stigmatized attitudes towards sex workers among health care providers.

Furthermore, communications with FSWs should not be based on the

assumption that they were merely vulnerable to contracting HIV/STDs, since this

study also revealed that FSWs face other work-related risks beyond STDs, such as

mental illness, addictions, and other chronic diseases. Health care providers need to

conduct a comprehensive assessment of all clients, using patient-centered care

principles.

At the societal level, community empowerment may be used to promote a

respectful environment for FSWs. The Sonagachi Project in India achieved success

in reducing the social stigma toward sex workers as well as empowering sex workers

(Gangopadhyay et al., 2005). It promoted human rights, provided condoms and

material resources, and created a sense of collective identity among FSWs. The local

NGOs in Hong Kong could play an essential role in promoting the recognition and

decriminalization of sex work, which, in turn, empower FSWs when accessing health

care services. Furthermore, open discussions on the best legal framework for dealing

with prostitution and protecting the human rights of prostitutes should be encouraged.

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Limitations of the study

The study was conducted among a subgroup of FSWs in Hong Kong (those

operating out of one-woman brothels). The findings of this study may not be

applicable to other groups of FSWs. A further study should be conducted of other

subgroups of FSWs, such as adolescent FSWs, sex-trafficked women, migrant FSWs,

or FSWs based in other venues.

Second, due to the highly sensitive nature of the topic, the possibility exists

that the FSWs gave socially desirable responses when describing their health, sexual

activities, and health behaviours towards the utilization of health care services.

10.4. Conclusion

Although stigma does not affect all FSWs when accessing health care services in the

study, it remains an important issue for a significant proportion of FSWs when they

seek timely professional help, fully disclose their secret of being involved in sex

work, and receive comprehensive health care services. Thus, stigma is still an

important aspect to address. The study also contributes to the existing literature on

various coping strategies that FSWs adopted in dealing with stigma in the health care

setting. Findings from the study also highlight the need for understanding and

addressing multiple healthcare needs of FSWs, and NGOs and the social hygiene

clinic may consider expand its services to other health concerns beyond STDs.

Moreover, it contributes to increasing awareness of, and respect for, the health care

needs and human rights of FSWs among health care professionals and students in the

health care professions.

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 Chapter 11

STUDY III Knowledge of, attitudes towards, and willingness to care for sex

workers: differences between general and mental health nursing students

11.1. Results

11.1.1. Demographic characteristics of the participants

11.1.2. Knowledge and education needs of the participants in relations to

caring for sex workers

11.1.3. Attitudes toward sex workers

11.1.4. Support for the human rights of sex workers

11.1.5. Willingness to care for sex workers

11.1.6. Factors associated with attitudes toward sex workers

11.1.7. Factors associated with Willingness to care for sex workers

11.2. Discussion

11.3. Implications

11.4. Conclusion

* Content of this chapter is published (partial content included in this chapter):

Ma, Haixia., & Loke, A. Y. (2020). Knowledge of, attitudes toward, and willingness

to care for female sex workers: differences between general and mental health

nursing student. Journal of rofessional Nursing (In press).

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11.1. Results

11.1.1. Demographic characteristics of the participants

In phase three, from January 2019 to March 2019, a total of 450 undergraduate

students were invited to take part in the study. A total of 327 students (80.0%)

returned the questionnaire electronically. However, 10 questionnaires were

incomplete and therefore discarded, leaving 317 questionnaires to be analyzed and

included in this study.

Of the 317 participants, 141 were studying in the general nursing programme,

and 176 in the mental health nursing programme, comprising 16.6% of the students

in the general programme and 50.3% of those in the mental health programme in the

School.

Table 11-1 shows the demographics of the participants. The students had a

mean age of 20.64 (SD=1.88), 76.0% were females, 85.5% were born in Hong Kong,

and 24.6% had a religious affiliation. The distribution of students studying in years

one to five was 85 (26.8%), 77 (24.3%), 51 (16.1%), 44 (13.9%), and 60 (18.9%),

respectively. Since more year-one students in the mental health nursing programme

and more year-five students in the general nursing programme took part in the study,

there were significant differences in the mean age of the students, with students in

the general programme being slightly older than those in the mental health

programme.

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Table 11-1 Demographic characteristics of the participants (N=317)

Factors Total General Mental health X2/t test p-

(n=317) nursing nursing value
n (%) (n=141) (n=176)
n (%) n (%)
Mean age (SD) 20.64 21.05 (1.983) 20.32 (1.864) 3.37 0.001
(1.949)
Gender
Male 76 (24.0) 24 (17.0) 52 (29.5) 6.74 0.009
Female 241 (76.0) 117 (83.0) 124 (70.5)
Place of origin
Hong Kong 275 (86.8) 121 (85.8) 154 (87.5) 0.20 0.903
Mainland 38 (12.0) 18 (12.8) 20 (11.4)
China
Overseas 4 (1.3) 2 (1.4) 2 (1.1)
Religion affiliation
Yes 78 (24.6) 36 (25.5) 42 (23.9) 0.117 0.732
No 239 (75.4) 105 (74.5) 134 (76.1)
Year of study 12.47 0.014
Year one 85 (26.8) 26 (18.4) 59 (33.5) 9.08 0.003
Year two 77 (24.3) 32 (22.7) 45 (25.6) 0.35 0.553
Year three 51 (16.1) 26 (18.4) 25 (14.2) 1.04 0.308
Year four 44 (13.9) 23 (16.3) 21 (11.9) 1.26 0.262
Year five 60 (18.9) 34 (24.1) 26 (14.8) 4.45 0.035
District
Hong Kong Island 48 (15.1) 20 (14.2) 28 (15.9) 2.50 0.287
Kowloon 85 (26.8) 44 (31.2) 41 (23.3)
New territories 184 (58.0) 77 (54.6) 107 (60.8)

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11.1.2. Knowledge and educational needs of the participants in relation to

caring for sex workers

Table 11-2 shows the knowledge and educational needs of students in relation to

caring for sex workers. Only a small percentage (3.8%) of students knew anyone

who was a sex worker, and 22.7% claimed that they could recognize people who

might be sex workers. Only one-quarter (25.2%) knew that prostitution was not

illegal according to Hong Kong‘s prostitution law.

When students were asked about their education in relation to caring for sex

workers, only 14.5% said that they had ever attended lectures, courses, or

community forums about sex workers, and 85.5% reported that they had never

received sex work-related training. Only a few students (3.2%) expressed the belief

that they have a good knowledge of how to care for sex workers. The majority

perceived a need for related knowledge on caring for sex workers (82.0%) and said

that such content should be included in the nursing curriculum (75.4%). Most said

that they would prefer to receive such training in workshops / seminars (53.9%) and

in lectures (47.9%). However, 5.7% of the participants were not interested in

receiving such training. There was a statistically significant difference between the

students in the two programmes in their preference in educational approach, with the

students in the general nursing programme preferring workshops / seminars

(X2=4.852, p=.028) and volunteer training offered by non-governmental

organizations (X2=4.351, p=.037).

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Table 11-2 Knowledge or training of students related to care for sex workers

Total General Mental X2 test p-

(n=317) nursing health value
n (%) (n=141) nursing
n (%) (n=176)
n (%)
Interpersonal contact with sex
workers
Yes 12 (3.8) 5 (3.5) 7 (4.0) 0.040 0.842
No 305 (96.2) 136 (96.5) 169 (96.0)
Can recognize a person as sex worker
Yes 72 (22.7) 32 (22.7) 40 (22.7) 3.491 0.175
No /not sure 245(77.3) 109 977.3) 136 (77.3)
Knowledge of prostitution law in Hong Kong
Prostitution is legal 62 (19.6) 25 (17.7) 37 (21.0) 2.105 0.551
Prostitution is illegal 126 54 (38.3) 72 (40.9)
(39.7)
Prostitution is not 80 (25.2) 41 (29.1) 39 (22.2)
illegal
No idea 49 (15.5) 21 (14.9) 28 (15.9)
Ever received training related to caring for sex workers
Yes 46 (14.5) 21 (14.9) 25 (14.2) 0.030 0.863
No or can‘t 271 (85.5) 120 (85.1) 151 (85.8)
remember
Hours of education on caring for sex workers in nursing curriculum
None 223 (70.3) 100 (70.9) 123 (69.9) 1.286 0.526
1-5h 78 (24.6) 32 (22.7) 46 (26.1)
>5 h 16 (5.0) 9 (6.4) 7 (4.0)
Self-rated knowledge about caring for sex workers
No or very little 28 (8.8) 16 (11.3) 12 (6.8) 4.262 0.119
Some knowledge 279 (88.0) 123 (87.2) 156 (88.6)
Good knowledge 10 (3.2) 2 (1.4) 8 (4.5)
Perceived need for having knowledge in caring for sex workers
Yes 260 (82.0) 120 (85.1) 140 (79.5) 1.641 0.200
No 57 (18.0) 21 (14.9) 36 (20.5)
Perceived need for addressing sex workers in nursing curriculum
Yes 239 (75.4) 112 (79.4) 127 (72.2) 1.767 0.184
No 78 (24.6) 29 (20.6) 49 (27.8)
Prefer education approach to acquire knowledge related to caring for sex workers
Lecture 152 (47.9) 63 (44.7) 89 (50.6) 1.193 0.275
Workshop / 171 (53.9) 86 (61.0) 85 (48.3) 4.852 0.028
seminar
Service - learning 100 (31.5) 39 (27.7) 61 (34.7) 1.870 0.171
Self-directed 71 (22.4) 28 (19.9) 43 (24.4) 0.996 0.318
learning
NGO volunteer 106 (33.4) 56 (39.7) 50 (28.4) 4.351 0.037
training
Not interested to 18 (5.7) 4 (2.8) 14 (8.0) 3.875 0.054
attend

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11.1.3. Attitudes toward sex workers

Table 11-3 presents the attitudes of students towards sex workers. Polarization was

observed in the students‘ attitudes toward prostitution. Nearly one third (27.8%) of

the participants called for prostitution to be legalized, while one third (28.1%)

opposed legalization. Almost one third (31.2%) expressed the view that prostitution

was immoral, while one third (27.8%) disagreed with this statement (had a positive

attitude).

Of the students, 70.7% believed that sex workers should undergo compulsory

medical tests, and 68.5% thought that they should be routinely tested for HIV /

sexually transmitted diseases (STDs). A majority (68.5%) also expressed sympathy

for sex workers who had contacted HIV/STDs through sex work (68.5%), and 62.5%

agreed that sex workers should be given free condoms.

A chi-square test and an independent sample t-test were conducted to

examine the differences between the two groups in their attitudes toward sex workers

(Table 11-3). A statistically significant difference was found between the two groups

of students in their attitude that ‗sex workers who become infected with HIV/STDs

deserve no sympathy‘, in that students in the general nursing programme were more

sympathetic, while those in the mental health programme were more neutral

(X2=9.217, p=0.01). There were no statistically significant differences between the

two groups in their overall mean score on attitudes toward sex workers (t=0.669,

p=0.504).

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 Table 11-3 Attitudes of students toward sex workers
Items Total General Mental X2 test p-
(N=317) nursing health value
n (%) (n=141) nursing
n (%) (n=176)
n (%)
Prostitution should be legalized 0.42 0.81
Disagree/strongly disagree 89 (28.1) 42 (29.8) 47 (26.7)
Neutral 140 (44.2) 60 (42.6) 80 (45.5)
Agree/strongly agree 88 (27.8) 39 (27.7) 49 (27.8)
Prostitution is immoral 1.52 0.47
Disagree/strongly disagree 88 (27.8) 38 (27.0) 50 (28.4)
Neutral 130 (41.0) 54 (38.3) 76 (43.2)
Agree/strongly agree 99 (31.2) 49 (34.8) 50 (28.4)
Prostitution is a sin 0.94 0.63
Disagree/strongly disagree 135 (42.6) 62 (44.0) 73 (41.5)
Neutral 148 (46.7) 62 (44.0) 86 (48.9)
Agree/strongly agree 34 (10.7) 17 (12.1) 17 (9.7)
There should be compulsory medical tests of sex workers 5.33 0.07
Disagree/strongly disagree 19 (6.0) 11 (7.8) 8 (4.5)
Neutral 74 (23.3) 25 (17.7) 49 (27.8)
Agree/strongly agree 224 (70.7) 105 (74.5) 119 (67.6)
Before admission to hospital, sex workers should be routinely tested for 1.57 0.46
HIV/STDs
Disagree/strongly disagree 23 (7.3) 13 (9.2) 10 (5.7)
Neutral 74 (23.3) 31 (22.0) 43 (24.4)
Agree/strongly agree 220 (69.4) 97 (68.8) 123 (69.9)
Sex workers who become infected with HIV/STDs deserve no 9.22 0.01
sympathy
Disagree/strongly disagree 217 (68.5) 106 (75.2) 111 (63.1)
Neutral 75 (23.7) 22 (15.6) 53 (30.1)
Agree/strongly agree 25 (7.9) 13 (9.2) 12 (6.8)
Sex workers who get HIV/STDs through their activity should have 0.65 0.72
to pay for medical care
Disagree/strongly disagree 64 (20.2) 30 (21.3) 34 (19.3)
Neutral 136 (42.9) 57 (40.4) 79 (44.9)
Agree/strongly agree 117 (36.9) 54 (38.3) 63 (35.8)
Sex workers should be given free condoms to reduce the spread of 0.64 0.73
HIV/STDs
Disagree/strongly disagree 38 (12.0) 17 (12.1) 21 (11.9)
Neutral 81 (25.6) 33 (23.4) 48 (27.3)
Agree/strongly agree 198 (62.5) 91 (64.5) 107 (60.8)
Total score Mean (SD): Mean Mean (SD): t-test 0.50
24.07 (3.338) (SD): 23.96 (3.388) value
24.21 0.67
(3.282)
Note: The negatively worded items were reversed in their scoring, including item 2-7 in the attitudes
toward FSWs scale.

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11.1.4. Support for the human rights of sex workers

Table 11-4 presents the students‘ support for the human rights of sex workers. Over

80% of the students in both programmes expressed support for the human rights of

sex workers, including for their right to quality of life, health and safety, and equal

treatment. A chi-square test and independent t-test were used to assess the

differences between the two groups on this issue.

The students in the general nursing programme were more supportive of the

right of sex workers to nondiscrimination and equal treatment (item 1), to marry and

start a family (item 4), to privacy of their personal information (item 5), to have

access to the highest attainable standard of health (item 7), to benefit from health-

related progress in the sciences, such as in areas related to the prevention of harm

(item 8), and to have access to the basic necessities to ensure an adequate standard of

living (item 9) (X2 test, all p<0.05). The results showed that students in the general

nursing programme were more supportive of the human rights of sex workers than

students in the mental health programme (t=2.817, p=0.005).

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Table 11-4 Support of human rights of sex workers among students (N=317)
Scales Total General Mental X2 p-
(N=317) nursing health test value
n (%) (n=141) nursing /t-test
n (%) (n=176)
n (%)
Sex workers have the right to nondiscrimination and equal treatment. 7.726 0.021
Disagree/strongly disagree 9 (2.8) 2 (1.4) 7 (4.0)
Neutral 48 (15.1) 14 (9.9) 34 (19.3)
Agree/strongly agree 260 (82.0) 125 (88.7) 135 (76.7)
Sex workers have the right to life, including quality of life. 3.888 0.143
Disagree/strongly disagree 5 (1.6) 2 (1.4) 3 (1.7)
Neutral 45 (14.2) 14 (9.9) 31 (17.6)
Agree/strongly agree 267 (84.2) 125 (88.7) 142 (80.7)
Sex workers have the right to maintain their physical integrity, without 4.518 0.104
fear of violence.
Disagree/strongly disagree 5 (1.6) 1 (0.7) 4 (2.3)
Neutral 46 (14.5) 15 (10.6) 31 (17.6)
Agree/strongly agree 266 (83.9) 125 (88.7) 141 (80.1)
Sex workers have the right to marry and start a family. 6.002 0.050
Disagree/strongly disagree 6 (1.9) 1 (0.7) 5 (2.8)
Neutral 55 (17.4) 18 (12.8) 37 (21.0)
Agree/strongly agree 256 (80.8) 122 (86.5) 134 (76.1)
Sex workers have the right to privacy of their personal information. 6.672 0.036
Disagree/strongly disagree 5 (1.6) 1 (0.7) 4 (2.3)
Neutral 45 (14.2) 13 (9.2) 32 (18.2)
Agree/strongly agree 267 (84.2) 127 (90.1) 140 (79.5)
Sex workers have the right to information and education that may 4.831 0.089
affect their well-being.
Disagree/strongly disagree 2 (0.6) 1 (0.7) 1 (.6)
Neutral 47 (14.8) 14 (9.9) 33 (18.8)
Agree/strongly agree 268 (84.5) 126 (89.4) 142 (80.7)
Sex workers have right to access the highest attainable standard of 7.770 0.021
health (physical and psychosocial).
Disagree/strongly disagree 4 (1.3) 1 (0.7) 3 (1.7)
Neutral 48 (15.1) 13 (9.2) 35 (19.9)
Agree/strongly agree 265 (83.6) 127 (90.1) 138 (78.4)
Sex workers have the right to benefit from health-related scientific 7.487 0.024
progress.
Disagree/strongly disagree 5 (1.6) 1 (0.7) 4 (2.3)
Neutral 49 (15.5) 14 (9.9) 35 (19.9)
Agree/strongly agree 263 (83.0) 126 (89.4) 137 (77.8)
Sex workers have the right to access the basic necessities (housing, 6.647 0.036
food, and clothing) for an adequate standard of living.
Disagree/strongly disagree 4 (1.3) 1 (0.7) 3 (1.7)
Neutral 54 (18.3) 16 (11.3) 38 (21.6)
Agree/strongly agree 259 (81.7) 124 (87.9) 135 (76.7)
Total score 36.99 38.00 36.18 2.817# 0.005
(5.791)* (5.258)* (6.080)*
*Data is presented as mean (SD).

200
11.1.5. Willingness to care for sex workers

Table 11-5 presents the willingness of students to care for sex workers. The majority

of the students responded positively, with 72.6% of them stating that they would

choose to provide care to sex workers, 77.6% that they would care for sex workers,

and 67.5% that they would be willing to care for them. However, 6.6% would not

provide care to sex workers if they were allowed to choose, and 3.5% would refuse

to care for them. A chi-square test and independent t-test analysis indicated that there

were no statistically significant differences between the students in the general and

mental health nursing programmes in their willingness to care for sex workers (all

p>0.05).

Table 11-5 Willingness of nursing students to care for sex workers (N=317)
Scales Total General Mental X2 p-
(N=317) nursing health test value
n (%) (n=141) nursing /t-
n (%) (n=176) test
n (%)
If I am allowed to choose, I will not choose to provide care to patients 1.575 0.455
who are sex workers
Disagree/strongly disagree 230 (72.6) 107 (75.9) 123 (69.9)
Neutral 66 (20.8) 25 (17.7) 41 (23.3)
Agree/strongly agree 21 (6.6) 9 (6.4) 12 (6.8)
I would refuse to care for patients who are sex 2.289 0.318
workers
Disagree/strongly disagree 246 (77.6) 115 (81.6) 131 (74.4)
Neutral 60 (18.9) 22 (15.6) 38 (21.6)
Agree/strongly agree 11 (3.5) 4 (2.8) 7 (4.0)
I am willing to take care of patients who are sex workers 4.684 0.096
Disagree/strongly disagree 13 (4.1) 4 (2.8) 9 (5.1)
Neutral 90 (28.4) 33 (23.4) 57 (32.4)
Agree/strongly agree 214 (67.5) 104 (73.8) 110 (62.5)
Total score Mean Mean (SD): Mean (SD): 1.629 0.104
(SD): 11.95 11.57
11.74 (2.071) (2.080)
(2.082)
Note: The negatively worded items were reversed in their scoring, including item 1-2 in the
willingness to care for FSWs scale.

201
11.1.6. Factors associated with attitudes toward sex workers

A linear regression analysis was conducted to identify the predictors of the students‘

attitudes towards sex workers (Table 11-6). The analysis was first conducted of the

students in the study as a whole, and then separately of students in the general

nursing and mental health nursing programmes.

The following variables were entered into the analysis: age, gender, religion,

birthplace, year of study, programme, district of residence, interpersonal contact with

sex workers, ability to recognize a person as a sex worker, knowledge of prostitution

law in Hong Kong, had received training related to sex workers, self-rated

knowledge about caring for sex workers, perceived a need to have knowledge about

caring for sex workers, perceived a need to address in the nursing curriculum issues

relating to sex workers, expressed support for the human rights of sex workers, and a

willingness to care for sex workers. Six negative statements (items 2 to 7) were

reverse-scored to compute the total score for attitudes.

The results showed that nursing students who were willing to care for sex

workers, perceived the need to have knowledge relating to the care of sex workers,

and who were in year five (the final year) of the programme had more positive

attitudes toward sex workers. The three variables explained 7.7% of the variance in

attitudes toward sex workers among all the nursing students.

The factors associated with positive attitudes toward sex workers among

students in the general nursing programme were self-rated good knowledge related

to sex workers, a willingness to care, and a perception of the need for related

knowledge. The three variables explained 19.9% of the variance in attitudes toward

sex workers among students in the general nursing programme. The factors

associated with a positive attitude on the part of students in the mental health nursing

202
programme were a perception of the need to have related knowledge and being in

one‘s final year of study. The two variables explained 4.8% of the variance in

attitudes toward sex workers among students in the mental health nursing

programme.

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Table 11-6 Stepwise linear regression to identify the correlating factors of students’ attitudes toward sex workers
Variables Categories b SE Beta t p 95% CI
All nursing students
1
Constant 19.381 1.065 18.204 0.000 17.287-21.476
Willingness to care for FSWs total score 0.296 0.092 0.184 3.220 0.001 0.115-0.477
Perceived need for having knowledge relating to Yes 1.247 0.504 0.142 2.473 0.014 0.255-2.239
sex workers
Year of study Year five 1.034 0.467 0.122 2.216 0.027 0.116-1.953
(Reference group: year 1)
Students in the general nursing programme
2
Constant 20.010 1.542 12.973 0.000 16.960-23.060
Self-rated knowledge of FSWs Good 7.007 2.192 0.253 3.197 0.002 2.673-11.341
(reference group: little or no knowledge) knowledge
Willingness to care for FSWs total score 0.347 0.130 0.219 2.671 0.008 0.090-0.603
Gender Female -1.636 0.677 -0.188 -2.416 0.017 (-2.974)-(-0.297)
(ref: male)
Perceived need for having knowledge relating to Yes 1.549 0.745 0.169 2.079 0.039 0.076-3.022
sex workers
Students in the mental health nursing programme
3
Constant 22.485 0.582 38.602 0.000 21.335-23.635
Perceived need for having knowledge relating to Yes 1.560 0.635 0.182 2.457 0.015 0.307-2.813
sex workers
Year of study Year five 1.584 0.706 0.167 2.244 0.026 0.190-2.978
(ref: year 1)
1
R=0.277, R2=0.077, adjusted R2=0.068, F=8.629, Model p=0.000.
2
R=0.446, R2=0.199, adjusted R2=0.176, F=8.456, Model p=0.000.
3
R=0.242, R2=0.059, adjusted R2=0.048, F=5.338, Model p=0.006.

204
11.1.7. Factors associated with the willingness of students to care for sex

workers

A linear regression analysis was conducted to identify the predictors of the nursing

students‘ willingness to care for sex workers. Separate analyses were conducted for

students in the general nursing and mental health nursing programmes (Table 11-7).

The following variables were entered into the analysis: age, gender, religion,

birthplace, year of study, programme, district of residence, interpersonal contact with

sex workers, the ability to recognize a person as a sex worker, knowledge of

prostitution law in Hong Kong, the receipt of training related to sex workers, self-

rated knowledge about caring for sex workers, the perception of a need to have

knowledge about caring for sex workers, the expression of a need to address sex

workers in the nursing curriculum, attitudes toward sex workers, and support for the

human rights of sex workers. Two negative statements (item 1 and item 2) were

reverse-scored to compute the total score on willingness.

The results showed that predictors of the willingness of nursing students to

care for sex workers in their future career were the expression of a need to have

knowledge about caring for sex workers, the ability to recognize a person as a sex

worker, the holding of positive attitudes toward sex workers, and the expression of

support for the human rights of sex workers. The four variables explained 36.2% of

the variance among all nursing students in the willingness to care for sex workers.

The factors associated with a willingness among students in the general

nursing programme to care for sex workers were the expression of a need to have

knowledge about caring for sex workers, the ability to recognize a person as sex

worker, the holding of positive attitudes toward sex workers, and the expression of

support for the human rights of sex workers. The four variables explained 36.1% of

205
Table 11-7 Stepwise linear regression of the correlating factors for the willingness of nursing students to care for sex workers
Variables Categories b SE Beta t p 95% CI
All nursing students
1
Constant 2.815 0.842 3.343 0.001 1.158-4.472
Support for FSWs‘ human rights total score 0.179 0.017 0.500 10.634 0.000 0.146-0.212
Perceived need for having knowledge relating to sex Yes 0.812 0.257 0.149 3.165 0.002 0.307-1.317
workers
Able to recognize FSWs in daily lives Yes 0.576 0.226 0.116 2.556 0.011 0.133-1.020
Attitudes toward FSWs total score 0.063 0.029 0.102 2.202 0.028 0.007-.120
Students in the general nursing programme
2
Constant 1.760 1.381 1.275 0.205 (-0.970)-4.490
Support for FSWs‘ human rights total score 0.177 0.028 0.449 6.315 0.000 0.122-0.232
Attitudes toward FSWs total score 0.105 0.045 0.167 2.362 0.020 0.017-0.194
Perceived need for having knowledge relating to sex Yes 0.885 0.411 0.153 2.153 0.033 0.072-1.698
workers
Able to recognize FSWs in daily lives Yes 0.715 0.343 0.145 2.083 0.039 0.036-1.393
Students in the mental health nursing programme
3
Constant 3.994 0.749 5.331 0.000 2.515-5.474
Support for FSWs‘ human rights total score 0.185 0.021 0.546 8.839 0.000 0.144-0.227
Perceived need for having knowledge relating to sex Yes 0.770 0.324 0.148 2.381 0.018 0.132-1.409
workers
Knowledge of the local prostitution law Correct 0.618 0.299 0.124 2.069 0.040 0.028-1.208
(ref: incorrect answer)
Religion Yes 0.588 0.292 0.121 2.009 0.046 0.010-1.165
(ref: none)
1
R=0.609, R2=0.371, adjusted R2=0.362, F=45.626, Model p=0.000.
2
R=0.600, R2=0.361, adjusted R2=0.342, F=19.167, Model p=0.000.
3
R=0.631, R2=0.399, adjusted R2=0.384, F=28.010, Model p=0.000.

206
the variance among students in the general nursing programme in the willingness to

care for sex workers.

The factors associated with a willingness of students in the mental health

nursing programme to care for sex workers were a religious affiliation, a perception

of the need to have knowledge about caring for sex workers, correct knowledge of

the prostitution law in Hong Kong, and support for the human rights of sex workers.

The four variables explained 39.9% of the variance among students in the mental

health nursing programme in the willingness to care for sex workers.

11.2. Discussion

This is the first study to explore and compare the knowledge, attitudes, and

willingness to care for sex workers of nursing students studying in general and

mental health nursing programmes in Hong Kong, and the factors associated with

these attitudes and willingness. It was encouraging to find that the majority of

students had a positive attitude, expressed support for the human rights of sex

workers, and were willing to care for them, although they were lacking in related

knowledge.

Inadequate knowledge about sex workers

The findings from the study showed that nursing students had little or inaccurate

knowledge about prostitutes and prostitution law in Hong Kong. Similar results were

reported on medical students‘ knowledge of sex workers (Nakagawa & Akpinar-Elci,

2014). The stigma associated with sex work and the legal constraints on prostitution

have compelled sex workers to hide, causing them to become invisible, ignored, and

forgotten in society (Decker et al., 2015; W. C. Wong et al., 2011).

207
 The coverage of sex workers in the nursing curriculum is considered

inadequate, as the students reported having not received related information from

their nursing curriculum. The nursing schools, as a microcosm of society, appear to

have avoided a topic that is commonly regarded as controversial. Similar findings

have also been reported on nursing students‘ understanding of other marginalized

and vulnerable populations, such as the lesbian, gay, bisexual, and transgender

(LGBT) community, drug abusers, and victims of domestic violence (Cornelius &

Carrick, 2015; Doran & Hutchinson, 2017; Vargas Vilela, Ventura, & Silva, 2010).

Also, studies have shown that nursing students are generally given little chance in

their studies to talk about topics related to sexuality, beyond discussions about sexual

and reproductive health problems (Aaberg, 2016; Carabez et al., 2015). The

inadequate knowledge and training in the nursing curriculum might raise concerns

about the competence of nursing students in caring for sex workers after graduation.

Thus, introducing sensitive topics about disadvantaged and marginalized populations

in the nursing curriculum, such as sex workers, may help to promote an

understanding of marginalized and vulnerable patients and result in more sensitive

care.

Polarized attitudes towards sex workers

In line with the literature, the nursing students, as members of society, expressed

polarized views towards sex workers (Lai et al., 2015; Ma et al., 2018b). Although

there has been a progressive shift in public attitudes towards sexuality and sexual

behaviours in recent years (Loper, Lau, & Lau, 2014; Yip et al., 2013), some of the

participants still held stereotyped and prejudicial attitudes towards sex workers,

reflecting the social norms and moral values of society.

208
 In Hong Kong, both traditional Confucianism and western Christianity have

had a deep impact on the construction of norms and attitudes towards sexuality (Chiu,

2006; Kwok & Wu, 2015). In the Confucian philosophy, it is considered proper for

women to be less sexually aggressive than men (Gao et al., 2012). In Christianity,

only sex within marriage is approved, while extramarital sex is condemned (Chiu,

2006). In addition, in Hong Kong the law states that ‗a person who in a public place

or in view of the public solicits for any immoral purpose‘ shall be guilty of an

offense (Hong Kong Crimes Ordinance (Cap 200), 1990). Therefore, it is not

surprising that sex work was viewed by participants in this study as immoral and

unethical.

It is worth noting that approximately 70% of the students agreed that sex

workers should undergo compulsory medical tests and be routinely tested for

HIV/AIDS. This finding is consistent with that from a study of nurses in Northern

Ireland, who held strong views on the control and regulation of sex workers (Melby

et al., 1992). Such prejudice or fear against sex workers (Schaffauser, 2010) may

reinforce the already stigmatized belief that sex workers are ‗vectors of disease‘

(Global Network of Sex Worker Projects, 2015). The control and regulation of sex

workers may violate the human right to have control over one‘s health and medical

screening (Bekker et al., 2015; Decker et al., 2015). There is also no evidence that

mandatory or compulsory testing would contribute to public health (Bekker et al.,

2015; Decker et al., 2015). The World Health Organization (WHO) has

recommended that voluntary HIV testing and counselling be offered to sex workers

at least annually, whenever they request it (World Health Organization, 2013). It is

essential to raise the awareness of students that they may hold stereotypes about sex

workers and that sex workers have the right to decide on their screening or treatment.

209
Support for the human rights of sex workers

It is comforting to know that the majority of the nursing students expressed respect

for the human rights of sex workers, particularly of their right to quality of life and

equal access to health and healthcare services. Their support for the human rights of

sex workers may be partially attributed to their knowledge of the nursing code of

professional conduct. The code provides guidance on professional conduct and ethics

in nursing. It clearly states that nurses must respect the dignity, values, and beliefs of

patients, and provide them with equal treatment regardless of the patients‘

background. Nurses are also required to safeguard the confidentiality and privacy of

their patients (The Nursing Council of Hong Kong, 2015). Pro-prostitution feminists

and activists with non-governmental organizations in Hong Kong have also put

tremendous effort into public education, and have called for the decriminalization of

prostitution (Lim, 2008; Marchetti, 2015). Their advocacy activities may have

increased the public‘s awareness of the human rights of sex workers.

Willingness to care for sex workers

The majority of the nursing students in this study were willing to care for sex

workers. The finding is similar to that reported in a study of medical students, in

which the majority indicated that they were willing to care for clients regardless of

background, including those who were sex workers (Nakagawa & Akpinar-Elci,

2014). This demonstrated the potential of these students to provide equal care for all

patients in their future practice, and thereby uphold the code of professional ethics.

However, the evidence also indicated that personal values, along with

societal and organizational values, may have an impact on how health workers

210
behave (Ellis, 2017; Horton, Tschudin, & Forget, 2007). It is also possible that

deeply rooted negative feelings about sex work may surface when these

professionals come in contact with these clients, so that they fail to safeguard the

equal rights of sex workers to healthcare services, creating a dissonance between

their prejudicial attitudes towards marginalized populations and the expectations of a

professional nurse (Pickles, de Lacey, & King, 2017).

It is therefore essential that nursing educators emphasize the professional

code of conduct of nurses, and nurture in their students a sense of self-awareness and

a habit of reflecting on their possible prejudicial and judgmental attitudes towards

sex workers and other marginalized populations. The possible association between

personal bias and the intended / unintended mistreatment of disadvantaged

populations should also be discussed.

Correlating factors on attitudes towards and a willingness to care for sex workers

The findings from the study suggest a significant association between the nursing

students‘ attitudes towards sex workers and their willingness to care for them. The

finding of a positive association between the attitude of healthcare providers towards

a stigmatized population and their willingness to care for members of that population

is consistent and supported by evidence (Hou et al., 2006; Suominen et al., 2010;

Yen et al., 2007).

The results of this study revealed an association between the nursing students‘

perception of a need for related knowledge and their attitudes towards and

willingness to care for sex workers. Those who did not see the need for such

information had negative attitudes and were unwilling to care for sex workers. This

finding may be explained by the selective exposure theory (Hart et al., 2009). People

211
who hold negative attitudes are likely to defend their attitudes, beliefs, and

behaviours by avoiding information that challenges their beliefs (Festinger, 1962;

Hart et al., 2009; Sweeny, Melnyk, Miller, & Shepperd, 2010). The students who had

negative attitudes towards sex workers may be resistant to changing their prejudice

through learning about this population group. This personal bias will undoubtedly

influence their future practice and service to these clients. How best to motivate

these students to participate in related interventions / educational programmes will

be a challenge.

The results of the study also showed that year-five students had more positive

attitudes towards sex workers than year-one students. One possible explanation for

this is simply that students in their fifth year in university are more mature than

freshmen. Final- year students may be more knowledgeable about sexual health and

the professional code of ethics of nurses than first-year students. Also, the subjects

‗Ethics and Legal Aspects in Health Care‘ and ‗Sexual and Reproductive Nursing

Care‘ are taught in year-three of the two programmes. Another possible explanation

is that students in their final year of study have had more clinical placements in

various clinical settings and have had opportunities to work with diverse populations.

A study had also found that final-year nursing students had more positive attitudes

towards older people as compared to first-year nursing students (Lambrinou, Sourtzi,

Kalokerinou, & Lemonidou, 2009). It is possible that final-year students have a

higher level of competency and are better prepared to deal with differences than first-

year students. Future studies are recommended to explore how subjects in the

nursing curriculum help to prepare nursing graduates with the competence to provide

care to marginalized populations.

An interesting finding was that being able to recognize sex workers in daily

212
life was associated with a willingness to care for them. Those who were able to

identify sex workers in public places were likely to have been able to do so through

the clothes that sex workers wear, the way that they talk, or other identifiers. This

may reflect an awareness and some understanding of the sex trade and the sex

workers. This contrasted with the finding that health care providers were likely to

show negative attitudes and an unwillingness to care for clients if they could identity

sex workers among HIV/STD patients (Phrasisombath et al., 2012). In healthcare

settings, healthcare providers may suspect that a client is a sex worker if that client

has a sexually transmitted disease or a history of contracting such diseases.

Healthcare professionals may be more likely to make moral judgements about sex

workers with sexually transmitted diseases as people who practise irresponsible

behaviours (Hood & Friedman, 2011).

The results from this study show that there was no statistically significant

difference between students in the general nursing and mental health nursing

programmes in their attitudes and willingness to care for sex workers. However,

there was a clear difference between the two groups in their support for the human

rights of sex workers. Surprisingly, there was a statistical significance between

general nursing students and mental health nursing students on their support for the

human rights of sex workers. Mental health nursing students scored lower on their

support for the human rights of sex workers as compared to general nursing students.

While students in mental health indicated that they are prepared to care for patients

with mental illnesses, they unexpectedly showed less inclination than students in

general nursing to respect the human rights of marginalized population groups.

However, this finding should be interpreted with caution, as there is a possibility of

sample bias. The response rates of the students from the general and the mental

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health programmes were 16.6% and 45.5% respectively, and more of the latter than

the former were in their first two years of study (41.1% vs 59.1%). The variation in

the response rate of the students may due to the class arrangement at the time of the

study, and that the teacher who invited the students showed interest in this topic as

well.

11.3. Implications

Due to the mobile and hidden nature of the work, there are no estimates of the

number of sex workers in Hong Kong. However, based on the outreach efforts of

non-governmental organizations in Hong Kong, there were perhaps anywhere from

20,000 to 100,000 sex workers in the city in 2001 (Ziteng, 2001). In the past two

decades, there has been a dramatic increase in the number of sex workers crossing

the border from mainland China into Hong Kong (Cheung, 2012; Ziteng, 2001).

Given the special health needs of sex workers, students in nursing should be

prepared to care for this special group of clients. The results of this study indicate

that there is a need to reform the current nursing curriculum to better prepare nursing

students to care for diverse populations.

First, social justice is the foundation of health equity (Hatchett, Elster,

Wasson, Anderson, & Parsi, 2015). It should be the underpinning for how decisions

are made in terms of equitable distribution and the allocation of healthcare services

and resources (Shaw & Degazon, 2008). The American Association of Colleges of

Nursing have recommended that social justice be considered an essential part of the

baccalaureate level of education for professional nurses (American Association of

Colleges of Nursing, 2008). A good understanding of social justice may help to

prepare future nurses to address health disparities and complex social problems.

They may also be able to reflect on how personal biases and stereotypes could lead

214
to social injustice and health disparities for stigmatized populations.

Second, the development of a culture of respect and support for the human

rights of patients holds the potential to empower both patients and advocates of

social justice. The negative attitudes of nurses may contribute to violations of the

human rights of sex workers stemming from the norms manifested in the clinical

environment. The promotion of human rights is encouraged and should be

incorporated into nursing education and professional training.

Third, there is a need to develop intervention programmes in professional

education to reduce the prejudices and biases of healthcare students. As the Equality

Challenge Unit emphasized, ‗It is not enough to simply alert people to the existence

of bias and/or to alert them to their own particular biases; people need to be given

strategies for addressing their biases which make them feel empowered and

autonomous, rather than guilty and controlled‘ (p.68) (Equality Challenge Unit,

2013). Stigma-reduction intervention programmes through education or other

strategies, such as contact with marginalized populations, have been shown to be

effective at lessening prejudicial attitudes towards stigmatized groups, such as

people living with HIV, patients with mental illness, and drug abusers (Dalky, 2012;

Heijnders & Van Der Meij, 2006; Livingston, Milne, Fang, & Amari, 2012; Sengupta

et al., 2011). Strategies may be borrowed from successful programmes.

Limitations of this study

First, the generalizability of the findings is limited due to the low participation rate

and to the use of convenience sampling from one university in Hong Kong. The

participants represent only around 26.0% of the total student population in that

university‘s School of Nursing. Given the sensitive nature of this study, many

215
students might have decided not to participate; thus, there is a possibility of selection

bias. Second, the study may have failed to include all critical predictive variables,

since the multiple linear models only explain 7.7% of the variance in attitudes

towards sex workers, with 92.3% of the variance unexplored. Third, the cross-

sectional nature of this study has limited the ability of the researchers to determine

causal relationships.

11.4. Conclusion

This study contributes to an understanding of the knowledge, attitudes, and

willingness of undergraduate nursing students in mental health and in general

nursing programmes to care for sex workers. This study found that undergraduate

nursing students had an overall low level of knowledge of sex workers, and that their

attitudes were polarized.

A perceived need to have related knowledge was associated with both

positive attitudes and a willingness to care for sex workers. This study showed that it

is essential to improve the attitudes of nursing students and their support for the

human rights of sex workers to improve their willingness to care for sex workers in

their future practice. The findings emphasized the need to prepare competent nursing

graduates to address health disparities from a social justice perspective. The

development of self-awareness and self-reflection may enable nursing graduates to

provide non-judgmental care. Moreover, to minimize fears and prejudicial attitudes

towards sex workers, it is recommended that stigma-reduction intervention

programmes be conducted.

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 Chapter 12

IDENTIFYNG / DEVELOPING THEORY

A preliminary conceptual framework to understand the

stigma toward sex workers among nurses

[Link] social ecological model identified from the qualitative study

[Link] from the literature review

[Link] conceptual framework to reduce stigma towards sex workers

among nurses

[Link]

217
According to the MRC framework, theory or conceptual framework is an essential

element in the development of a complex intervention (Craig et al., 2008; Medical

Research Council, 2019). It is defined as a network of interlinked concepts that

serves the purpose of understanding a phenomenon of interest (Jabareen, 2009).

Only a complex intervention will be developed based on the fundamental concepts of

a comprehensive framework.

This chapter presents a proposed preliminary conceptual framework to

understand stigma toward sex workers among nurses based on the findings of

reviews of literature and from the qualitative and quantitative studies, with the

ultimate aim to reduce stigma towards sex workers among nurses and disparities in

the health and health care access among sex workers in Hong Kong.

12.1. The social-ecological model identified from the qualitative study

The social-ecological model (SEM) was used to understand the interactive effects of

multi-level factors on behaviours, including intrapersonal, interpersonal, institutional,

community, and policy levels (McLeroy, Bibeau, Steckler, & Glanz, 1988). A

number of existing stigma framework is developed based on the social-ecological

model (Hatzenbuehler et al., 2013; Logie, James, Tharao, & Loutfy, 2011;

Pescosolido, Martin, Lang, & Olafsdottir, 2008; Stangl et al., 2019). Based on this

model, a modified SEM-NrSw was proposed in the qualitative study among nurses

to better understand the personal attitudes and professional practices of nurses in

caring for sex workers (Chapter 9). It could inform education or training programs

to enhance the self-reflection of nurses and the provision of quality of care for sex

workers.

The modified SEM-NrSw suggested that multi-level factors had a powerful

influence on the attitudes and clinical practices of nurses when caring for sex

218
workers: intrapersonal, interpersonal, institutional, and community. Moreover, the

findings from the cross-sectional survey among nursing students provided additional

information on the factors associated with nursing students‘ attitudes or willingness

to care for sex workers, including knowledge of sex workers (i.e. the ability to

recognize a person as sex workers), a perceived need for education relating to caring

for sex workers, the year of study, and support for the human rights of sex workers

(Chapter 11).

The SEM suggests that multiple-level intervention may be more effective

than targeting a single level of the SEM (Paskett et al., 2016). Yet, it may not be

feasible to conduct a multi-level intervention to reduce the stigma towards caring for

sex workers at the current stage. For example, the structural level intervention is

considered as one of the most effective ways to address the stigma associated with

sex work. The researchers and the sex worker activists call for the decriminalization

of prostitution (Decker et al., 2015). However, changes the law is hardly achievable

through an intervention.

12.2. Theories from the literature review

Through the process of scoping review of HIV/AIDS-related stigma reduction

intervention among professionals and students from health-related disciplines, it was

suggested that the social cognitive theory and the intergroup contact theory could be

adopted when developing interventions to reduce the stigma towards sex workers

among nurses. The social cognitive theory and the intergroup contact theory are

useful to understand the origin and remediation of prejudice (Aboud, 2008; Allport

et al., 1954).

219
Social cognitive theory

The social cognitive theory (SCT) developed by Albert Bandura in 1960s was

originally used to explain the health behaviour. It is the most widely adopted theory

in HIV/AIDS-related stigma reduction intervention among health care professionals

and students in the health-related disciplines. It is suggested that the individual could

learn attitudes and reactions by observing others in social contexts (Bandura, 2009;

Bandura & Walters, 1977). This theory emphasizes on the triadic reciprocal

causation in which personal factors (i.e., cognitive, affective, and biological events),

environmental influences, and behaviours continually interact (Bandura & Walters,

1977). The SCT is suitable for explaining the impact of multi-level factors (i.e.

personal and environmental level factors) on a specific behaviour change.

According to the SCT, the health-related knowledge, the self-efficacy, the

goals, the outcome expectation, and socio-structural factors are the core determinants

of one‘s health behaviours (Bandura, 2004). Self-efficacy is a vital element of the

social cognitive theory, which represents the level of confidence in one‘s ability to

perform a behaviour (Bandura, 1997). It provides the foundation for one‘s

motivation, accomplishments, and well-being (Bandura, 2010). As a critical

determinant, self-efficacy could affect the behaviour directly or indirectly through its

impacts on goals, outcome expectations, and socio-structural factors (Bandura, 2004).

It is a partial mediator that connects knowledge and behaviour (Sukserm &

Takahashi, 2012). In the HIV/AIDS-related stigma reduction interventions, self-

efficacy links the knowledge of health care professionals‘ confidence in and their

competency in caring for PLWHA (Reid, 2005).

The SCT provides a theoretical base for the understanding of stigma at the

societal level (Corrigan, 2000), and has been widely used in health behaviour

220
interventions, such as nutrition, physical activities, substance abuse, and sexual

behaviours (Painter, Borba, Hynes, Mays, & Glanz, 2008).

Intergroup contact theory

Intergroup contact theory proposed that prejudice is generated due to the lack of

positive personal contact or low levels of contact among members between different

groups (Allport et al., 1954; Pettigrew & Tropp, 2006). Positive intergroup contact

could lead to more positive intergroup contact. It is more likely to occur under four

conditions: equal status, common goals, intergroup cooperation, and institutional

support (Allport et al., 1954). Findings from a meta-analysis of 515 studies

suggested that intergroup contact theory was particularly effective in reduction

intergroup prejudice (Pettigrew & Tropp, 2006). Intergroup contact theory has been

widely used in reducing the stigmatized attitudes toward various disadvantaged

groups (Chaudoir et al., 2017; Couture & Penn, 2003; Heijnders & Van Der Meij,

2006).

12.3. A preliminary conceptual framework to understand the stigma toward sex

workers among nurses

Based on the theories and models that were described, a preliminary conceptual

framework to understand the stigma toward sex workers among nurses was proposed

(Figure 12-1). It included the following three domains: multilevel factors influencing

stigma toward sex workers among nurses; stigma mediators, and stigma outcomes.

This process occurs within a broader social, cultural, and legal context.

221
 Stigma outcomes
Stereotype (knowledge) Prejudice (attitudes) Discrimination (behaviours)

- Knowledge of sex - Attitudes toward sex - Willingness to care for sex

workers workers workers
- Knowledge of - Self-efficacy
HIV/AIDS - Support for the human
rights of sex workers

Stigma Mediators
 Knowledge  Awareness of negative stereotypes
- Knowledge of sex workers  Self-efficacy
- Knowledge of HIV/AIDS - Universal precautions
- Code of ethics and professional conduct - Communication skills
 Support for the human rights of sex workers  Contact with sex workers

Nursing curriculum/training
Sex workers Nurses /clinical practice
 Characteristics  Characteristics  Training to prepare cultural
 Reason for engaging in sex  Belief/value of sexual Conflicts competency nurse:
work practice and relationships between - Code of ethics and
 Types of sex workers Dynamic  Knowledge of sex work personal & professional conduct
interaction professional - Role modelling
 Health condition and sex industry

attitudes - Clinical rules and
 Self-stigma Personal experience with
regulations
sex workers
 Clinical norm toward sex
 Training
workers

Social, cultural, legal context

Figure 12-1 Preliminary conceptual framework to understand stigma toward sex workers among nurses
222
 For our target population, multilevel factors could influence the stigma

toward sex workers among nurses. The social-ecological model depicted the

intrapersonal, interpersonal, institutional, as well as broader social, cultural, legal,

and environmental context could influence nurses‘ professional practice. At the

intrapersonal level, various factors could influence their attitudes toward sex workers,

such as the characteristics of nurses, their personal beliefs and values of sexual

practice and relationships, knowledge of sex work and the sex industry, and personal

experience with sex workers, and training received.

At the interpersonal level, the characteristics of sex workers, the reasons for

engaging in sex work, self-stigma, the health condition, and the dynamic interaction

between nurses and sex workers, can also be influential. At the institutional level, the

training to prepare cultural competence nurse could influence nurses‘ attitudes, such

as the professional code of ethics and conduct, role modelling, clinical rules and

regulations. Clinical norms could impact nurses‘ professional practices. Since

personal and professional attitudes are intertwined and inseparable. The conflict

between their personal and professional beliefs may contribute to their endorsement

of stigmatizing attitudes toward sex workers in their practice.

The domain of stigma mediators included the following components:

knowledge (i.e., knowledge of sex worker, knowledge of HIV/AIDS, knowledge of

code of ethics and professional conduct), support for the human rights of sex workers,

awareness of negative stereotypes, self-efficacy (i.e., universal precautions,

communication skills), and contact with sex workers. Findings from the review of

the HIV/AIDS-related stigma reduction interventions suggested that providing

information about the stigmatized population could contribute to increase of the

awareness of personal negative stereotypes and reduce the stigmatized attitudes

223
among professionals and students from health-related disciplines. Such as

information about the stigmatized condition (i.e. HIV/AIDS), the code of

professional ethics, the human rights of the stigmatized population (Chapter 6). The

self-efficacy include nurses‘ universal precautions skills and communication skills

with sex workers. According to the intergroup theory, contact was an essential factor

in reducing stigma between two different groups (Allport et al., 1954). Contact may

foster empathy and minimize the distance between nurses and sex workers, and

reduce myth and prejudice about sex workers.

The domain of stigma outcome included knowledge, attitudes, and

behaviours. According to the social cognitive model, stigma consists of three

components: stereotype (knowledge), prejudice (attitudes), and discrimination

(behaviours) (Corrigan, 2000; Corrigan, Edwards, et al., 2001) (Corrigan & Watson,

2002; Thornicroft et al., 2007). Knowledge of sex worker and HIV/AIDS will be

used to reflect the stereotype about sex workers. Attitudes toward sex workers, self-

efficacy, and support for human rights of sex workers will be used to reflect the

prejudice toward sex workers. Discrimination is indicated by nurses‘ willingness to

care for sex workers in their practice.

It is worth noting that the contextual factors may affect the endorsement of

stigma toward sex workers among the nurses, including the social, cultural, and legal

factors.

12.4. Summary

In the present chapter, a preliminary conceptual framework to understand the stigma

toward sex workers among nurses was proposed. The exploration of the inter-

relationship among different domains will aid the development of a complex

224
intervention that aims at reducing the stigma toward sex workers among nurses. It is

hoped that such an intervention will result in improvement in stigma outcomes,

including knowledge, attitudes, and willingness to care for sex workers in their

practice. It is also hoped that such an intervention would reduce the health care

disparities of sex workers in the long run.

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 Chapter 13

MODELLING THE PROCESS AND OUTCOMES

The development of a complex intervention: reduce stigma towards sex workers

among nurses

13.1. The identified evidence

13.1.1. Evidence from the literature review

13.1.2. Evidence from the sequential qualitative-quantitative study

[Link] proposed theory

[Link] developed intervention to reduce stigma towards sex workers among nurses

[Link]

226
In following the MRC framework, a series of literature reviews have been carried out

to identify the evidence, identify/develop a framework, and develop an intervention

to reduce the stigma associated with sex work among nurses. This chapter aims to

describe the process of developing a complex intervention to reduce the stigma

toward caring for sex workers among nurses in Hong Kong.

The MRC framework was adopted to guide the development of the

intervention to reduce the stigma towards caring for sex workers among nurses in

Hong Kong. According to the MRC framework, there are four phases in the process

of developing and implementing a complex intervention: development,

feasibility/piloting, evaluation, and implementation (Medical Research Council,

2019). The development stage consists of three steps: identifying the evidence base,

identifying/developing theory, and modelling process and outcomes (Craig et al.,

2008). The first stage of development of the complex intervention was included in

the thesis.

13.1. The identified evidence

According to the Medical Research Council (MRC) framework (Craig et al., 2008;

Medical Research Council, 2019), the first step in developing a complex intervention

is to identify the evidence through conducting a series of reviews and identify

evidence from a series of studies in Hong Kong.

13.1.1. Evidence from the literature review

A series of literature reviews were conducted to better understand the impact of

stigma on sex workers‘ motherhood (Ma, Chan, & Loke, 2019); the attitudes of

different stakeholders towards sex workers (Ma et al., 2018b), the barriers and

227
facilitators to the accessing of health services by sex workers (Ma et al., 2017), and

to examine the effects of HIV/AIDS-related stigma-reduction intervention for

professionals and students in health-related disciplines, to shed light on the

development of stigma-reduction interventions related to sex work (Chapter 6). The

thorough review of the literature created a solid foundation for the understanding of

the stigma of sex work and associated health care services. The conceptualization of

stigma suggested that stigma consists of three components: stereotype, prejudice, and

discrimination (Chapter 5). Stigma has a significant impact on sex workers

occupational health and safety, and their health-seeking behaviours. These reviews

highlighted the need to improve sex workers‘ health care services uptake through

reducing health care providers‘ negative attitudes toward sex workers.

Although there was a lack of intervention focusing on reducing the stigma of

health professionals towards sex workers, interventions related to HIV/AIDS could

be used as a reference to develop stigma-reduction interventions for health

professionals with regard to sex work (Chapter 6). Recommendations for stigma-

reduction interventions related to sex work among professionals and students from

health disciplines are given below:

 Approaches and contents of interventions: Multiple-components

intervention was suggested, such as providing of information, building of

skills, counselling, contacting with or sharing by PLWHA, biomedical

protection, and structural approaches.

 Theoretical framework: None, but findings from the scoping review

recommended that the social cognitive theory and intergroup contact

theory could be adopted when developing interventions to reduce the

stigma towards caring for sex workers among professionals and students

228
 from health-related disciplines. A preliminary conceptual framework may

be developed based on the suggested theories.

 It is concluded that multiple approaches and a longer duration / multiple

sessions should be adopted in interventions which aim to reduce the

stigma towards caring for sex workers among professionals and students

from health-related disciplines.

 Delivery of intervention: Face-to-face Intervention should be delivered by

trained professionals. The professionals may include HIV experts, trained

health care professionals, staff members from sex worker organizations,

and sex workers.

 Outcomes of intervention: The outcomes of intervention should include

knowledge of sex workers, attitudes toward sex workers, and willingness

to care for sex workers.

The review of the literature provided a solid foundation for the understanding

of stigma of sex work and associated health care services, identify research gaps, and

offered recommendations for the reduction of stigma associated with sex work

among professionals and students from health disciplines.

13.1.2. Evidence from a series of studies in Hong Kong

The findings from a series of studies in Hong Kong suggested that multi-level stigma

associated with sex work and STDs played a significant role in influencing the health

care-seeking behaviours of female sex workers (FSWs). Non-judgmental holistic

health care could facilitate the uptake of health care services of FSWs. Although

nurses in Hong Kong held conflicting, inconsistent, and ambivalent personal feelings

229
towards sex workers, all of the participants understood their professional nursing

code of ethics and conceded that they were obligated to provide equal care to all

patients regardless of their background. Nurses‘ specialties, clinical experience, and

training may contribute to their ease, confidence, and willingness to care for sex

workers. Thus, it is suggested that intervention should be provided to nurses to

provide care to diverse populations.

13.2. The proposed theory

According to the MRC framework to develop a complex intervention, the second

step is developing a conceptual framework. A preliminary conceptual framework to

understand the stigma toward sex workers among nurses was proposed. It consisted

of three domains: multilevel factors influencing stigma toward sex workers among

nurses; stigma mediators, and stigma outcomes. This process occurs within a broader

social, cultural, and legal context (Chapter 12).

13.3. The developed intervention to reduce stigma towards sex workers

among nurses

An intervention is proposed based on the characteristics of related interventions from

a scoping review of HIV/AIDS-related stigma reduction interventions aimed to

reduce stigma among professional and students from health-related disciplines

(Chapter 6).

Intervention

Key elements of the intervention

The key elements of the intervention have been developed according to the

230
preliminary conceptual framework for nurses (see Figure 13-1). It takes into

consideration of three domains: multilevel factors influencing stigma of sex worker

among nurses; stigma mediators, and stigma outcomes. The intervention is a two-

consecutive-day workshop with six sessions, and each session will last 2 hours. The

sessions will cover the following topics: an introduction of stigma (session 1), the

stigma associated with sex work (session 2), sex work-related stigma in the

healthcare setting (session 3), nursing ethical obligations (session 4), skills to reduce

stigma toward sex workers (session 5), and ideas to promote stigma-free services

(session 6).

Approaches

The intervention will adopt a combination of three approaches: providing

information, skills building, and contact with sex workers.

1) Information approach

Information related stigma and its consequences on health disparities will be

provided to nurses. Nurses will participate in a reflection activity and think about a

time in their life when they feel stigmatized.

2) Skills building approach

Skills building refers to the learning of strategies to resolve negative attitudes,

coping strategies, and hands-on skills (Brown et al., 2003; Stangl et al., 2013). In this

programme, skills building mainly focuses on the development of universal

precautions skills, communication skills, and sexual history taking skills.

231
 3) Contact approach

To reduce the myth of sex workers, direct face-to-face interactions between the

nurses and sex workers will be conducted. The guest sex worker will share her life

stories, and experiences of stigma in the healthcare setting, and reflections on how

stigma affects her health care-seeking behaviour.

Delivery of intervention
The research investigator will be one of the intervention providers of the study. She

is a registered nurse in Mainland China and also a public health professional with

experience in providing sexual and reproductive health service for sex workers in

Hong Kong (Jun 2010 to Dec 2010). She participated in HIV/STI prevention and

treatment outreach in bars, nightclubs, massage parlor, one-woman-brothel, and the

streets. She also received volunteer training on Drug Issues of Ethnic Minority Sex

Workers from Action for Research Out in 2016, and volunteer training on male sex

workers from the Midnight Blue in 2019. The workshop will also invite speakers

including a sex worker and sex worker activists (i.e. peer educators and AFRO staff).

232
 Session 6: Ideas to promote
stigma-free services
Stigma outcomes
Stereotype (knowledge) Prejudice (attitudes) Discrimination (behaviours)

- Knowledge of sex - Attitudes toward - Willingness to care for

workers sex workers sex workers
- Knowledge of - Self-efficacy
Session 3: Sex work-related stigma HIV/AIDS - Support for the Session 5: Skills to reduce
in the healthcare setting human rights of sex stigma toward sex workers
workers

Stigma Mediators
Session 1: An
 Knowledge  Awareness of negative stereotypes
Session 4: Nursing introduction of stigma
- Knowledge of sex workers  Self-efficacy
ethical obligations
- Knowledge of HIV/AIDS - Universal precautions
- Code of ethics and professional conduct - Communication skills Session 2: The stigma
 Support for the human rights of sex workers  Contact with sex workers associated with sex work

Sex workers Nursing curriculum

 Characteristics /clinical practice
Nurses 
 Reason for engaging in sex Training to prepare cultural
 Characteristics Conflicts competency nurse:
work
 Belief/value of sexual between - The professional code
 Types of sex workers Dynamic
practice and relationships personal & of ethics and conduct
 Health condition interaction
 Knowledge of sex professional - Role modelling
 Self-stigma attitudes - Clinical rules and
workers
 Personal experience with regulations
sex workers - Universal precautions
 Training  Clinical norm toward sex
workers

Social, cultural, legal context

Figure 13-1 The key elements and focus of the intervention developed based on a preliminary conceptual framework for nurses

233
Table 13-1 Main contents and delivering outline of the intervention
Session title Objectives Content Intervention
approach
Day one Session 1: An  To increase the awareness  Participants will be asked ―what do you think is the meaning Information, skills
introduction of of stigma. of stigma‖ at the beginning of the first session. building
stigma  To increase the awareness  As participants will give their ideas, record them in a circle
of stigma in health care. diagram, then the researcher will give a 15-min PowerPoint
presentation on stigma: including the definition of stigma,
types of stigma, and consequences of stigma on health
services.
 After that, participants will be given 30-min to think about a
time in their life when they feel stigmatized (reflection
exercise), and share their experience with a partner, and then
discuss with a larger group.
Session 2: The  To increase the knowledge  NGO staff will provide participants with the information Information
stigma associated of sex industry in Hong about prostitution law and sex industry in Hong Kong.
with sex work Kong.  They will start the session with questions, such as describing a
sex worker, reasons of entering into the sex industry, attitudes
toward sex worker, slang used in the sex industry, and asking
the participants about prostitution law in Hong Kong.
 They will correct false ideas about the prostitution law and
sex worker.
 They will describe the current situations of sex workers in
Hong Kong, their human rights, stigma, and different types of
violence from police and clients.
Session 3: Sex  To increase the  This session will be delivered by a sex worker and staff from Contact with sex
work-related stigma understanding of health the NGO. At the beginning of the session, participants will be worker
in the healthcare and health care services of asked to respect the confidentiality of the guest speaker.
setting sex workers;  The guest speaker will share her story regarding her life as a
 To reduce the myth of sex sex worker, experiences of stigma in the healthcare setting,

234
 Session title Objectives Content Intervention
approach
workers; and reflections on how stigma affects her health care-seeking
 To increase the awareness behaviour.
of personal attitudes.  The participants will have the opportunity to ask questions,
either openly or anonymously by submitting written
questions.
 After that, the guest speaker will share examples of positive
experiences in the healthcare setting and brainstorm with
students about strategies that could be employed to decrease
stigmatizing behaviours in the health setting.
Day two Session 4: Nursing  To increase the knowledge  Participants will be asked to reflect back on their own attitude Information
ethical obligations of professional and behaviour toward sex workers and/or other marginalized
obligations; populations, and will be asked: ―What can we do to make a
 To increase the knowledge difference in sex workers lives?‖
of the human rights of sex  The researcher will further emphasis patient‘s rights, legal
workers. and professional obligations in treating patients, clarify
nurses‘ supportive role in caring for sex workers. Meanwhile,
the occupational safety standards for nurses, such as universal
precautions will also be addressed.
 After the presentation, the participants will be divided into
small groups, and discuss ―How can we stop stigma in our
future practice?‖
 Using the suggested approaches as the basis for paired role-
play.
Session 5: Skills to  To increase the knowledge  The nurse will share her experience of offering sexual and Information, skills
reduce stigma of the sexual and reproductive health services for sex workers. building
toward sex workers reproductive health of sex  Information on HIV/AIDS, disease prevention, and universal
workers; precautions will be mentioned.
 To build universal  Communication skills in counseling and assessment will be
precaution skills; emphasized, such as how to reduce sex workers‘ anxiety, how

235
Session title Objectives Content Intervention
approach
 To increase the to raise sensitive health topics, skills to build trust and
communicating with sex respect.
workers.  The participants will have the opportunity to ask questions.
 In the second half of the session, the participants will be
divided into small groups, and practice the effective way of
raising sensitive topics.
Session 6: Ideas to  Overview the programme;  At the beginning of this session, the participants will be Information
promote stigma-free  To identify strategies to divided into small groups, they will be asked to write down
services reduce stigma toward the lessons learned from the workshop, discuss ideas to
marginalized populations promote stigma-free services.
in practice.  Then the participants will give a group presentation.
 At the end of this session, they will be asked to fill the post-
test questionnaire and evaluation form of the workshop.

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Outcome measurements

Based on the preliminary conceptual framework to understand the stigma towards

sex worker among nurses, the expected outcome measures are: knowledge, attitudes,

and willingness to care for sex workers. Since there is a lack of standardized

measurement of stigma toward sex works, the preliminary questionnaire will be

developed based on an extensive literature review and validated by experts. The

validity and reliability of the questionnaire will be tested before the implementation

of the intervention.

Knowledge of sex workers will be measured using self-developed questions.

The items will explore the nurses‘ knowledge of sex workers, the local prostitution

law, and knowledge of HIV/AIDS.

Nurses‘ attitudes toward sex workers will be measured using a scale

developed by Melby V et al. (1992). It is a 5-point Likert scale (1 = strongly disagree,

5 = strongly agree). The scale assesses three aspects of attitudes: morals, control, and

sympathy. The Cronbach‘s alpha reliability was reported to be 0.653 in the previous

cross-sectional study (Chapter 11).

Nurses‘ self-efficacy will be developed based on previous studies assessing

the level of comfort and confidence of health care professionals with providing care

to people who were living with HIV/AIDS (Bluespruce et al., 2001). It will be a 5-

point Likert scale (1 = strongly disagree, 5 = strongly agree). The eight-item self-

efficacy scale will include two aspects of self-efficacy: comfort and confidence. For

example, students will be asked about whether they feel confident that they get

accurate information about sexual behaviour from sex workers, whether they have

been well trained to take a sexual history, whether they feel comfortable asking sex

workers about sexual practices.

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 Nurses‘ support for the human rights of sex workers will be measured by nine

self-developed items. The nine items were developed based on notions concerning

women‘s sexual and reproductive health and rights as laid out by the United Nations‘

Office of the High Commissioner for Human Rights (The Office of the High

Commissioner of Human Rights, 2014). Responses were measured on a 5-point

Likert scale (1 = strongly disagree, 5 = strongly agree). The total score of the scale

ranged from 9 to 45 points, with a higher score indicating more support for the

human rights of sex workers. Cronbach‘s alpha reliability was reported to be 0.967 in

the previous cross-sectional study (Chapter 11).

Nurses‘ willingness to care for sex workers will be measured by using three

self-developed items: (1) If I am allowed to choose, I would not choose to serve

patients who are sex workers; (2) I would refuse to care for patients who are sex

workers; (3) I am willing to take care of patients who are sex workers. Responses to

each item ranged from 1 (strongly disagree) to 5 (strongly agree). Items one and two

will be reversely scored, with a higher score representing a greater willingness to

care for sex workers. The Cronbach‘s alpha reliability was reported to be 0.745 in the

previous cross-sectional study (Chapter 11).

13.4 Summary

Guided by the MRC framework, an intervention to reduce stigma towards sex

workers among nurses was developed by using the preliminary conceptual

framework. This was done with supporting evidence from the reviews of the

literature, findings from the qualitative study among nurses, the qualitative study

among FSWs, and the cross-sectional study among nursing students. It is

recommended that a pilot study should be conducted to evaluate the feasibility of the

238
intervention programme proposed.

239
PART IV CONCLUSIONS AND SUGGESTIONS FOR FUTURE RESEARCH

240
 Chapter 14 Summary of the thesis

[Link]

[Link] findings

[Link] for practice

[Link]

14.4.1. Limitations of the literature reviews

14.4.2. Limitations of the qualitative and cross-sectional studies

[Link] for future research

[Link]

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14.1 Introduction

According to the Medical Research Council (MRC) framework, this thesis focused

on the first phase: development of a complex intervention. Following the MRC

guideline, a series of studies were conducted to identify the evidence,

identify/develop a framework, and develop a complex intervention (see Figure 14-1).

242
 Process of MRC framework Studies conducted Conclusions/Outcomes

 Literature reviews
Step 1  A series of studies to identify
There is a need for
Identifying the the local evidence
reducing stigma toward sex
evidence base Study I: A qualitative study
workers among nurses.
among practicing nurses
There is a lack of specific
Study II: A qualitative study
framework on reducing
among female sex workers
stigma toward sex workers
Study III: A cross-sectional
among nurses.
study among the
undergraduate nursing
Phase 1 students
Developing A preliminary conceptual
the complex framework to understand the
intervention Step 2 Developing a preliminary stigma toward sex workers
Identifying / conceptual framework among nurses was proposed,
developing which could be used as
theory guidance on the development of
a complex intervention.

An intervention to reduce
Step 3 Developing and presenting the stigma towards sex workers
Modelling related contents of intervention among nurses was developed
process and based on the preliminary
outcomes conceptual framework.

Figure 14-1 Steps taken and studies conducted corresponding to MRC framework

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14.2 Main findings

Stage I: Development of the complex intervention

Step 1: Identifying the evidence base

Review of the literature (Chapter 2-4, 6), the conceptualization of stigma

(Chapter 5), the qualitative study among nurses (Study I, Chapter 9), the

qualitative study among sex workers (Study II, Chapter 10), and the cross-

sectional study among nursing students (Study III, Chapter 11)

Chapter 7 summarized the main findings and identify the research gaps from the

literature (chapter 2-6). Most studies mainly focused on the attitudes of the general

public attitudes toward sex workers, few studies focused on health care providers‘

attitudes toward sex workers. Although extensive studies have highlighted the

importance of combating stigma associated with sex work in healthcare settings, and

few interventions were found specially focused on reducing the stigma toward sex

workers among professionals and students from health-related disciplines. Findings

obtained from these reviews provide sound evidence for the development of a

complex intervention.

Study I: The qualitative study among nurses identified four themes after the

content analysis. The four themes included generally conflicting attitudes toward sex

workers, the professional obligation to provide care to all, acknowledgement of one‘s

hesitation in caring for sex workers, and the preparations involved in caring for

patients who might be involved in sex work. A conceptual framework based on a

socio-ecological model (SEM-NrSw) could help to understand multilevel factors that

influence attitudes and clinical practices of nurses when caring for sex workers, it

244
could also inform the development of education or training programs to enhance the

self-reflection of nurses and the provision of quality of care to all.

Study II: The qualitative study among FSWs identified three themes after a

direct content analysis, including the experience of stigma in the health care setting;

coping with the stigma of sex work; and the call for non-judgmental holistic health

care. Stigma remains the key barrier to their seeking timely professional help, fully

disclosing their secret of being involved in sex work, and receiving comprehensive

health care services. It also contributes to increasing awareness of, and respect for,

the health care needs and human rights of FSWs among professionals and students

from health-related disciplines.

Study III: The cross-sectional study among 317 nursing students reported an

overall low knowledge of and polarized attitudes toward FSWs. The study confirms

the positive correlation between nursing student‘s attitudes, support for FSWs‘

human rights, and willingness to care for FSWs. The major factors that influence the

overall attitudes toward FSWs were the year of study, the perceived need for having

FSWs-related knowledge, and knowledge of prostitution law. The study provided

insights for preparing competent nurse in caring for FSWs and other marginalized

population.

Summary of the main findings:

• Nurses and nursing students had polarized and conflicted attitudes towards

sex workers;

• Nurses and nursing students were a lack of knowledge and training related to

caring for sex workers;

• Majority of the nurses and nursing students were obligated to provide equal

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 care to all patients, including sex workers;

• The subtle non-verbal behaviours unintentionally showed an attitude of

stigmatization towards sex workers (nurses & FSWs);

• Call for non-judgmental holistic health care when caring for sex workers.

Developing a preliminary conceptual framework (Chapter 12)

In Chapter 12, a preliminary conceptual framework to understand the stigma toward

sex workers among nurses was proposed. It was developed based on the social-

ecological model, the social cognitive theory, and intergroup contact theory. It could

potentially be used to guide the development of an intervention to reduce stigma

toward sex workers among nurses.

The proposed conceptual frameworks showed three interlinked components

relating to stigma toward sex workers among nurses. At the bottom of the diagram,

multilevel factors could influence stigma toward sex workers among nurses. In the

middle of the diagram, the domain of stigma mediators indicated that knowledge (i.e.

knowledge of sex work, knowledge of HIV/AIDS, knowledge of code of ethics and

professional conducts), support for the human rights of sex workers, awareness of

negative stereotypes, self-efficacy (i.e. universal precautions, communication skills),

and contact with sex workers may reinforce or reduce the stigma toward sex workers

among nurses. At the top of the diagram, the domain of stigma outcomes was

comprised of stereotype (knowledge), prejudice (attitudes), and discrimination

(behaviours).

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The development of a complex intervention: reduce stigma towards sex workers

among nurses (Chapter 13)

With the guidance of the conceptual framework, a programme to reduce stigma

towards sex workers among nurses was proposed. The intervention mainly targeted

the domain of stigma mediators. It will be a two-consecutive-day workshop with six

sessions, and each session will last 2 hours. The program will combine different

approaches, including providing information, skills building, and contact with sex

workers. The main focus of the programme is to improve nurses‘ knowledge of sex

work, HIV/AIDS, and code of ethics and professional conduct, and to improve their

self-efficacy in caring for sex workers, especially communication skills and

universal precautions. The programme also provides the opportunity to contact with

sex workers. The content of the programme includes an introduction of stigma

(session 1), the stigma associated with sex work (session 2), sex work-related stigma

in the healthcare setting (session 3), nursing ethical obligations (session 4), skills to

reduce stigma toward sex workers (session 5), and ideas to promote stigma-free

services (session 6).

14.3 Implications for practice

According to the MRC framework of developing a complex intervention, further

research need to test the feasibility/piloting the intervention, followed by evaluating

and implementing the intervention (Craig et al., 2008; Medical Research Council,

2019). Thus, it is recommended that a pilot/feasibility study should be conducted in

the next step to assess the feasibility of the study, such as the recruitment procedure,

the response rate, the drop-out rate, the validity and reliability of the measurements,

and estimate the sample size of the programme.

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14.4 Limitations

Although potential contributions have been made to reduce the disparities in access

to health care among sex workers. The projects have several limitations that needed

to be acknowledged.

Limitations of the literature reviews

The articles included in the four reviews were only those published in peer-reviewed

journals with English, which may increase the possibility of publication bias.

Another limitation was that the meta-analysis was not performed, which might limit

the generalization of the results. Thirdly, due to the sensitive nature of the topic, the

studies could not be free from the social desirability bias.

Limitations of qualitative study among nurses

The majority of the participants had little chance to care for sex workers, and they

only expressed their attitude towards and their care for patients who had been

diagnosed with HIV or STDs, and whom they suspected to be sex workers. Another

limitation is that the recruitment of the participants was based on convenience and

snowball sampling, the results of the study may not be generalized. Lastly, there is a

possibility that socially desirable responses were provided by the interviewed nurses

on this sensitive topic.

Limitations of qualitative study among female sex workers (FSWs)

The study was conducted among a subgroup of FSWs in Hong Kong (those

operating out of one-woman brothels). The findings of this study may not be

applicable to other groups of FSWs.

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 Second, due to the highly sensitive nature of the topic, it was possible that the

FSWs gave socially desirable responses when describing their health, sexual

activities, and health behaviours towards the utilization of health care services.

Limitation of cross-sectional study among nursing students

The participants represent only a small proportion of the total student population in

that university‘s School of Nursing, which may limit the generalizability of the

results. Another limitation was that the study may have failed to include all critical

predictive variables. Third, the cross-sectional nature of this study might limit the

ability of the researchers to determine causal relationships.

14.5. Summary

The findings, which emerged from two qualitative studies and quantitative survey

have contributed to a more holistic understanding of the attitudes toward sex workers

from the perspectives of sex workers, nurses, and nursing students. This study

contributes to a better understanding of the health care needs of FSWs in Hong Kong.

It also contributes to increasing awareness of, and respect for, the human right of

FSWs to receive non-discriminatory health services, informing the development of a

nursing curriculum for the promotion of non-judgmental care for sex workers or

disadvantaged client groups.

Guided by the MRC framework, this project has conducted the first stage of

developing a complex intervention. This stage involved three steps: identify the

relevant, existing evidence through conducting systematic reviews, identifying /

developing theory, and modelling a complex intervention. The subsequent

pilot/feasibility studies are recommended to test the feasibility of the intervention.

249
 LIST OF APPENDICES

Appendices

Table 2-1 Summary of studies on female sex workers‘ experience of

motherhood
Table 2-2 Prostitution law in countries included in the review
Table 2-3 Quality appraisal of selected studies
Table 3-1 Characteristics of the included studies
Table 3-2 Quality appraisal of selected studies
Table 4-1 Methodology quality appraisal of the included studies
Table 4-2 Characteristics of the included study
Table 4-3 Barriers to health services among sex workers
Table 4-4 Facilitators to health services among sex workers
Table 6-1 Quality appraisal with Downs and Black scale
Table 6-2 Characteristics of the included study
Table 6-3 Characteristics of interventions
Table 6-4 Effect size of HIV/AIDS related-knowledge
Table 6-5 Effect size of attitudes towards caring for PLWHA
Table 6-6 Effect size of behaviour towards PLWHA
Table 8-1 Content validity index of the items in the questionnaire
Table 8-2 Psychometric properties of the measurements
Appendix I Ethical Approval Letter for Qualitative Study of Nurses
Appendix II Information Sheet for Qualitative Study of Nurses*
Appendix III Consent Form for Qualitative Study of Nurses*
Appendix IV Appendix IV Ethical Approval Letter for Qualitative Study of
Female Sex Workers
Appendix V Appendix V Information Sheet for Qualitative Study of Female Sex
Workers*
Appendix VI Consent Form for Qualitative Study of Female Sex Workers*
Appendix VII Ethical Approval Letter for Cross-Sectional Study of Nursing
Students*
Appendix VIII Information Sheet for Cross-Sectional Study Among Nursing
Students*

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Appendix IX Consent Form for Cross-Sectional Study Among Nursing students*

Appendix X Appendix X Interview guide of the qualitative interview among

nurses_English version
Appendix XI Interview guide of the qualitative study of nurses (Chinese version)
Appendix XII Appendix XII Interview guide of the individual interview among
female sex workers (English version)
Appendix XIII Appendix XIII Interview guide of the individual interview among
female sex workers (Chinese version)
Appendix XIV Questionnaire of the cross-sectional survey among nursing students
Appendix XV Formulae for calculating effect size for RCT and quasi-experimental
study with controlled group
Appendix XVI Certificate of volunteer training

*English and Chinese versions included

251
Table 2-1: Summary of studies on female sex workers’ experience of motherhood
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
Qualitative studies
Conflicting identities Response to social expectation
between sex workers and on ideal motherhood
motherhood
Basu Ambar et al., To explore how 46 (93.9%); FSWs were described as  Stigma and laws that  Justification of sex work:
2011, does enunciation (32 FSWs, incapable mothers by the undermine FSWs‘ Money earned from sex work
India of sex worker 11 NGO staff, mainstream assumptions. abilities to be mothers: enabled their children to have
identity influence 3 husbands of And communication FSWs feared that their ―more respectable‖ jobs;
patterns of health FSWs) about health and children would be  Emphasis mothers‘
and HIV/AIDS (age: not reported) HIV/AIDS was practiced stigmatized. responsibility: They were very
communication. in the sex worker cautious about HIV/STDs and
community was the negotiated condom use;
children.  Social support networks: NGOs
in India provided FSWs with
practical help.
Beckham Sarah To explore the 30 (Response rate: Being mothers affected  Internalizing stigma:  Justification of sex work: They
W. intersections not reported); FSWs‘ negotiating power FSWs stated that they rationalized their work as being
et al. 2015, between (age range: 20-40y, in complex manners, felt ashamed to be for their children;
Tanzania motherhood, sex mean age: 28.9y) which led to both working as a sex worker.  Emphasis mothers‘
work, and HIV- increases in HIV related responsibility: Motherhood
related risk risk behaviours and helped FSWs to avoid the
behaviours among decreases in risk stigma of childlessness; led to
sex workers behaviours. an increase/decrease in condom
use, and to an increase in their
desire to test for HIV.

252
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
Bletzer Keith V., To 38 (Response rate: FSWs with children  Exposing children to an  Emphasis mothers‘
2006, ethnographically not reported); remained emotionally unsafe environment: responsibility: FSWs were
U.S. explore the (mean age: Black: close to their children Children repeated their emotionally close to their
influence of street 35.63, White: even when social contact mothers‘ experience children, some FSWs would
life on 33.29, Other: was limited or non- (e.g., were abused or limit their drug use during
childrearing by 35.40) existent. Their principle raped as children, pregnancy; some FSWs
women involved concern was assuring engaged in sex work); believed that their children were
in sex work and their children were raised  Internalizing stigma: better off being taken care of by
drug use in in the best way available. FSWs expressed that others;
agricultural areas they felt ashamed of  Restore positive social identity:
of the U.S. having their children see Children motivated mothers to
them as sex workers, and leave sex industry and complete
some FSWs used drugs drug treatment programs;
to self-medicate.  Social support networks: The
children of most FSWs were
living separately from their
mothers/taken care of by fathers
or extended family.

Dalla Rochelle, To explore how 38 (Response rate: Barriers to effective  Exposing children to an  Emphasis mothers‘
2004, and to what extent not reported); mothers at the individual, unsafe environment: responsibility: FSWs felt that
U.S. effective (mean age: 34.1y) community and societal FSWs continued their their children were better off
mothering can be levels. Suggestions for sex work and drug use being cared for by others;
promoted among promoting effective during pregnancy and  Restore positive social identity:
women involved mothering among FSWs had children born with FSWs had strong emotions
in street-level are also provided: fetal alcohol syndrome about their children. Children
prostitution. maternal well-being and or addicted to motivated mothers to complete
self-care at the individual substances, some FSWs‘ drug treatment programs;
level, community-based daughters became sex  Social support networks: FSWs
resources at the workers; left their children with extended
community level, and  Some FSWs lost custody family.
policy and advocacy at over their child;
the societal level.  Internalizing stigma:

253
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
FSWs expressed guilt
for hurting their family
and children, and
regretted missing out on
motherhood.
Dodsworth Jane, To explore the 24 (Response rate: There is a need to cope  Exposing children to an  Justification of sex work: Some
2012, impact of not reported); with the dual identities of unsafe environment: FSWs had a strong sense of
U.K. involvement in (age range: 18-65) FSWs and ―good Children of FSWs died/ self-efficacy and saw sex work
sex work on mother‖. The were placed in care/were as enabling them be a ―good
managing accumulated risk factors adopted/lived with mother‖;
motherhood. of early childhood and relatives;  Emphasis mothers‘
the resources available to  Internalizing stigma: responsibility: FSWs were
individuals in adulthood Losing their children emotionally close to their
were essential in was painful, and in children. The responsibility of
managing both identities. response FSWs motherhood motivated FSWs to
Services should increased their drug use start/leave sex work;
recognize individual, and sex work.  Restore positive social identity:
environmental and Children motivated mothers to
familial factors leave sex industry or complete
impacting on women drug treatment programs;
with the dual identities in  Social support networks: FSWs
order to promote their left their children with extended
resilience as mothers. family.
Goh Esther C.L. To understand the 5 (100%) The mother-child  Exposing children to an  Justification of sex work: Sex
& Praimkumara impact of the (age range: relationship context was unsafe environment: work helped them to fulfill their
Shamini, mother-child 21-36y) a key influence on Children of FSWs had maternal duties;
2015, Singapore relationship on FSWs‘ decision to enter been taken away by  Restore positive social identity:
sex workers‘ and/or leave the sex Social and Family Motherhood motivated FSWs
decision to enter industry. Social work Development services; leave the sex trade;
and leave the practice should meet the  Internalizing stigma:  Social support networks: NGOs
streets. needs of FSWs and their FSWs feared that their helped to meet their practical
children in a manner that children would follow in needs.
promotes agency and their footsteps, and they

254
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
preserves dignity. felt guilty about lying to
their children.
John-Fisk To understand the 17 (Response rate: Motherhood was an  Exposed children to an  Emphasis mothers‘
2013, social issues that not reported); important aspect in unsafe environment: responsibility: FSWs
India and U.S. sex workers face (age range: 30-48y) FSWs‘ lives. While they FSWs and their children emphasized their maternal
as mothers in both face great challenges in faced illness, poverty, duties and would do anything
India and the U.S. bring up their children. the lack of a safe shelter, for their children;
Supporting programs are FSWs in India expressed  Restore positive social identity:
needed to help FSWs and the fear that their Children motivated mothers to
their children. children would be leave sex industry or complete
bullied in school; drug treatment programs;
 Some American FSWs  Social support networks: FSWs
lost custody over their left their children with extended
children; family.
 Stigma and laws that
undermine FSWs‘
abilities to be mothers:
Children of FSWs would
be treated with
discrimination and
bullied at school;
 Internalizing stigma:
They felt ashamed and
had low self-esteem;
separation from children
caused FSWs to feel
depressed, and they
increased their sex work
and drug use.
McClelland To explore the 20 (Response rate: Drug use and prostitution  Exposing children to an  N.A.
Gabrielle Tracy & experiences and not reported); had actual and perceived unsafe environment:
Newell Robert, views of women (age range: 21-38y, harm on mothering. Children of FSWs were
2008, with children in mean age:30) Emphasis should be exposed to violence,

255
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
U.K. the context of placed upon the clients, drugs, or other
street-based proactive identification potential dangers;
prostitution and and implementation of  FSWs loss of custody
problematic drug positive supportive over their child;
use. strategies.  Internalizing stigma:
FSWs would increase
their sex work or drug
use to dull the pain of
separation from their
children.
Peled Einat & To explore the 8 (50%) Give children a good  Internalizing stigma:  Emphasis mothers‘
Parker Ayelet, mothering (age range: 25-32y) childhood was presented FSWs felt guilty about responsibility: FSWs tried to
2013, experiences of as prime motivation for not doing the right thing fulfill their maternal obligations
Israel sex-trafficked taking up prostitution. for their family, and they and ensure their children‘s
women. While painful and had a negative self- welfare. They felt pride over the
emotional childhood image. huge sacrifice they were
experiences seemed to making for their children;
play an important role in  Justification of sex work:
FSWs‘ constructions of Mothers showed self-esteem
good mothering. and felt proud about changing
their children‘s lives;
 Social support networks: FSWs
left their children with extended
family.
Rivers-Moore To explore how 136 (Response rate: Sex worker allows FSWs N.A.  Emphasis mothers‘
Megan, sex workers have not reported); to think of themselves as responsibility: Motherhood was
2010, experienced and participants (50 goo mothers. Survival, central to the sex workers‘
Costa Rica strategized their FSWs, 30 sex consumption, and ability to combat stigma at
working and tourists, 56 state, motherhood are work, FSWs engaged in sex
family lives in the NGO, and private discursively deployed, in trade for their children;
specific context of sector employees often contradictory and  Justification of sex work: Sex
neo-liberalism in (age: not reported) conflicting ways, in work allowed FSWs to think of
Latin America. order to counteract the themselves as ―a good mother‖

256
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
effects that stigma has on who was able to provide for and
FSWs. It is also spend quality time with her
suggested that FSWs children.
may very well be
quintessential subjects of
neo-liberalism in Latin
America, in their
embrace of
entrepreneurial work and
consumption.
Sloss Christine M To examine the 16 (80%) FSWs‘ pregnancies and  Exposed children to an  Emphasis mothers‘
& Harper Gary experiences of (age range: 20-46y, parenting altered their unsafe environment: Sex responsibility: FSWs expressed
W., 2004, women who are mean age: 32y) working productivity and work during pregnancy concern about their children‘s
U.S. involved in both practices, and their work posed multiple risks for safety when they were working;
parenting and also affected their their unborn baby; children and parenting had
street sex work parenting, they felt  FSWs had lost custody, altered their sex work practice;
and to determine ashamed of themselves gave up their children to they either increased or
the interaction of and their work and extended family, or had decreased their sex work;
these dual roles. anxious for their own their children removed  Restore positive social identity:
and their children‘s by child welfare Almost all of them wanted to
safety. FSWs who are authorities; stop sex for drugs.
mothers have unique  Internalizing stigma:
needs and experiences FSWs felt ashamed,
that must be considered. guilty and anxious, and
feared of the negative
consequences on their
unborn child; some
FSWs used drugs to self-
medicate.
Willis Brian, et To explore the 35 (Response rate: Stigmatization and  Exposed children to an N.A.
al., 2014, threats to the not reported) discrimination against unsafe environment: Sex
Bangladesh health and welfare brothel madams FSWs and their children work during pregnancy
of children of (age: >18y) are underlying conditions exposed their unborn

257
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
FSWs. that compromise their baby to multiple risks
access to health and that increased the
social services. Children changes of congenital
of FSWs are vulnerable birth defects, some
to numerous threats, mothers forced their
family-based support are daughters into sex work;
need to these mothers  Stigma and laws that
and children to meet undermine FSWs‘
basic needs, social abilities to be mothers:
welfare and other Children of FSWs
services. experience
stigmatization from
police officers/ schools/
landlords/ healthcare
provider.
Zalwango Flavia To explore the 96 (Response rate: FSWs distanced  Exposed children to an  Emphasis mothers‘
et al., 2010, lives and work not reported); themselves from the unsafe environment: responsibility: FSWs engaged
Uganda experiences of sex (age range: 19-55y) public discourse of sex Mothers solicited in sex work for their children;
workers. work as dishonorable and potential clients in front  Justification of sex work: Sex
shameful, the antithesis of their babies; work enabled FSWs to meet
of being good wife and  Internalizing stigma: their children‘s needs.
mother. FSWs felt ―in pain‖  Social support networks: FSWs
when bringing their baby left their children with extended
to solicit potential family.
clients. They felt
ashamed of their work.
Quantitative studies
Duff Putu To examine the 399 (Response rate: The prevalence of child  Exposed children to an
et al., 2015, barriers faced by not reported); apprehension among unsafe environment:
Canada sex workers to (age: >14y, median FSWs who were also  FSWs had lost custody
accessing age of participants mothers was 38.3%. and separated from
health/social reporting parenting Factors, such as children;
services while difficulties: 35y) servicing clients in  Internalizing stigma:

258
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
pregnant and outdoor public spaces FSWs experienced
parenting. (adjusted odds ratio barrier to accessing
(aOR)=2.73, 95% health/social and support
confidence interval (CI): services.
1.27 to 5.90) , history of
injecting drugs
(aOR=2.53, 95% CI:
1.42 to 4.49), aboriginal
ancestry (aOR=1.66,
95% CI: 1.01 to 2.74),
were associated with
increased odds of child
apprehension.
Papworth Erin et To evaluate the 696 (Response rate: Motherhood was N.A.  Emphasis mothers‘
al., 2015, determinants of not reported) predictive of having responsibility: Motherhood was
Burkina Faso motherhood (age: >18y) reduced condomless a significant predictor of a
among FSWs, vaginal or anal sex with a woman‘s entry into sex work to
their sexually new client [age-adjusted provide for her family;
risky behaviours, odds ratio (aaOR), 0.80; motherhood influenced the
and engagement 95% CI: 0.65 to 0.97] in behaviour of FSWs: reduced in
in healthcare. the past 30 days, and condomless vaginal or anal sex
increased condomless with new clients, limited
vaginal or anal sex with a difficulty when accessing health
nonpaying partner care.
(aaOR, 1.49; 95% CI:
1.13 to 1.96).
Motherhood was
prognostic of a higher
likelihood of ever being
tested for HIV (aaOR:
1.89, 95% CI: 1.55 to
2.31).
Duff Putu To examine the 350 (Response rate: 34% of the FSWs  Exposed children to an N.A.

259
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
et al., 2014, prevalence of the not reported); reported that they had unsafe environment: The
Canada apprehension of (age: > 14y, age one or more barriers to prevalence of child
the children of range: 19-61y) health/social and support apprehension: 38.3%;
FSWs in Canada. services while  Internalizing stigma:
pregnant/parenting role. FSWs receive
Lower education, counseling to deal with
homelessness, and the trauma of losing their
history of injecting drugs children.
were significantly
correlated with these
barriers.
Reed E. To examine 850 (Response rate: The challenging N.A.  Emphasis mothers‘
et al. 2013, whether the not reported); responsibilities related to responsibility: 85% of the
India responsibilities of (age > 18y, caretaking of children are FSWs reported entering sex
motherhood are median age=30y) associated with heighted work for their children and
associated with vulnerability to HIV risk families; motherhood
women's among FSWs. influenced mothers‘ health
vulnerability to behaviours: e.g. FSWs with ≧
HIV. 3 children were less likely to
report consistent condom use.
Yerpude Pravin & To describe the 87 (96.7%); 46.94% of children of the  Exposed children to an  Social support networks: Local
Jogdand Keerti, breastfeeding (age: <20y (9.19%) FSWs had been breast- unsafe environment: NGOs ran a residential school
2012, practice and child 21-29y (44.84%) fed for one year or more, children were raised in for the children of FSWs.
India placement option 30-39 y 18.37% were never the brothel;
chosen for (39.08%) breast-fed. 34.96% of  Stigma and laws that
children by > 40y (6.89%)) children of the FSWs undermine FSWs‘
brothel-based were being raised in the abilities to be mothers:
commercial sex brothel. The children Children of FSWs
workers in India. were kept in the brothels experienced difficulty
up to five years of age. getting admitted to
FSWs faced difficulties school.
in getting school
admission for their

260
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
children.
Combined quantitative and qualitative studies
Chege M.N., To determine the 385 (response rate: Finding from  Exposed children to an  Emphasis mothers‘
et al. 2002, childcare not stated) quantitative study: 3/4 of unsafe environment: e.g. responsibility: 28.8% of FSWs
Kenya practices of (age range: 18-49y, the participants practiced socialized daughters into had secured resources for the
commercial sex mean age = 32.4+ prostitution at home. the sex trade; they failed future maintenance of their
workers. 7y) About 3/4 of the mothers to seek treatment for children.
with adolescent children their children;
educated them on  Some of them lost
HIV/AIDS. Health custody over their child.
seeking behaviours for  Internalizing stigma:
the children were FSWs felt guilty about
hampered by health care using drugs.
cost and consumption of
alcohol by the mothers.
Only 2.0% took time to
converse or counsel the
children.
Findings from focus
group discussion:
children were left
unattended at night while
the mothers went out in
search of clients. Efforts
to provide better
education for the
children were
undermined by lack of
funds and truancy.1/3 of
the participants had
invested for the future
maintenance of their
children.

261
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
Pardeshi Geeta & To describe child 60 (100.0%); (age: In the process of raising  Exposed children to an  Emphasis mothers‘
Bhattacharya S., bearing, family < 20y (3.3%) their children, being a unsafe environment: responsibility: Children were
2006, support, dietary 21-29y (46.7%) single parent, stigma and Some FSWs continued regarded as hope for security
India practices, and 30-39y (46.7%) the profession, odd to work during and support; FSWs shouldered
various placement > 40y (3.3%)) working hours and pregnancy, children were the main responsibility of
options for raising variable family support raised in the brothel. providing financial support for
children amongst were major challenge for their children.
brothel-based FSWs; while the fact that  Social support networks: Some
commercial sex the women were earning, children were sent to a
workers. availability of residential school organized by
rehabilitation centers, the local NGOs.
homogeneous group
within the brothels,
supportive peers and the
local non-governmental
organizations were
factors which helped
them in the process of
raising their children.
Rolon Maria To explore the 428 (Response rate: Children strengthened  Exposed children to an  Emphasis mothers‘
Luisa et al., 2013, experience of not reported); (214 FSWs and their partners‘ unsafe environment responsibility: Children
Mexico-U.S. having children FSWs, relationship, concerns for  Lost custody over their strengthened the relationship of
border and its effects on 214 intimate non- children‘s well-being children: children were couples, and mothers were
FSWs and their commercial motivated couples to taken away from FSWs involved in sex work for their
intimate partners‘ partners) complete healthier by social services children; Motherhood
HIV risk (median age: 35y, lifestyle changes. authorities; influenced decisions made by
behaviours. age range: 29-42y) However, childbearing  Internalizing stigma: FSWs (to reduce drug use, find
costs motivated sex work Separation from children an alternative job, move to a
and structural constrains caused FSWs pain and safer place);
prevented couple from their drug use escalated.  Justification of sex work: FSWs
enacting lifestyle were not against sex work since
changes. it was for their family‘s own
good;

262
Author, Year, Aims Participants Main findings Themes
Country (Response rate %)
 Restore positive social identity:
Almost all of them wanted to
stop sex for drugs.
Abbreviations: FSWs: female sex workers; N.A.: Not applicable.

263
Table 2-2 Prostitution law in countries included in the review
Country Is Prostitution legal? Are brothels legal?
Africa
Burkina Faso Prostitution is not specifically prohibited by the law, but No
soliciting and pimping are illegal
Kenya Yes – However, it is illegal to live wholly or in part on the No
earning of prostitution and soliciting or importuning for
immoral purpose.
Tanzania No No
Uganda No No
Asia
Bangladesh Yes No
India Yes No
Israel Yes No
Singapore Yes – however, it is illegal to live on the earnings of sex No
work, to solicit in public to sell sex

Europe
United Yes – However, it is illegal to solicit to buy or sell sex in a No
Kingdom public place.
North
America
Canada Prostitution is limitedly legal No
Costa Rico Yes No
Mexico Yes No
United States No – Except Nevada No
Remark: Countries are arranged by alphabetical order.

264
Table 2-3 Quality appraisal of selected studies
QL Basu Beckham Bletzer Dalla Dodsworth Goh et John-Fisk McClella Peled et Rivers- Sloss et Willis et Zalwang
et al. et al. 2006 2004, 2012, al. 2013, nd et al. al. 2013, Moore al. 2004, al. 2014, o et al.
2011, 2015, U.S. U.S. UK 2015, India and 2008, Israel 2010, U.S. Banglades 2010,
India Tanzania Singapor U.S. UK Costa h Uganda
e Rica

Items
0.1. Y Y Y Y Y Y Y Y Y Y Y Y Y
0.2. Y Y Y Y Y Y Y Y Y Y Y Y Y
1.1. Y N N N N Y N N Y N Y N N
1.2. Y Y Y Y Y Y Y Y Y Y Y Y Y
1.3. Y Y Y Y Y Y Y Y Y Y Y Y Y
1.4. N N N N N N N Y Y N N N N
Score *** ** ** ** ** *** ** *** **** ** *** ** **
DS Duff Papwort Duff Reed Yerpude
et al. h et al. et al. et al. et al. 2012,
2015, 2015, 2014, 2013, India
Canada Burkina Canada India
Faso

Items
0.1. Y Y Y Y Y
0.2. Y Y Y Y Y
4.1. Y Y Y Y Y
4.2. N N N N N
4.3. Y Y Y Y UC
4.4. UC UC UC UC Y
Score ** ** ** ** **
MM Chege et al. Pardeshi et al. Rolon et al.
2002, 2006, 2013,
Kenya India Mexico-US

265
Items border
0.1. Y Y Y
0.2. Y Y Y
1.1. N N N
1.2. UC UC Y
1.3. Y Y Y
1.4. N N N
4.1. Y Y Y
4.2. N N N
4.3. UC UC Y
4.4. UC Y UC
5.1. Y Y Y
5.2. Y Y Y
5.3. N N N
Score * * **
Note: key: Y = Yes; N = No; UC = Unclear; QL = Qualitative study; DS: Quantitative descriptive study; MM: Mixed method study. For score, the higher number of *
indicates the better of the research quality. The lowest score is *, while the highest score is ****.
Items: 0.1. Are there clear qualitative & quantitative research questions (or objectives), or a clear mixed methods question (or objectives)? 0.2. Do the collected data allow
address the research question (objective)? E.g., consider whether the follow-up period is long enough for the outcome to occur (for longitudinal studies or study components).
1.1. Are the sources of qualitative data (archives, documents, informants, observations) relevant to address the research question (objective)? 1.2. Is the process for analysing
qualitative data relevant to address the research question (objective)? 1.3. Is appropriate consideration given to how findings relate to the context, e.g., the setting, in which
the data were collected? 1.4. Is appropriate consideration given to how findings relate to researchers‘ influence, e.g., through their interactions with participants? 4.1. Is the
sampling strategy relevant to address the quantitative research question (quantitative aspect of the mixed methods question)? 4.2. Is the sample representative of the
population understudy? 4.3. Are measurements appropriate (clear origin, or validity known, or st&ard instrument)? 4.4. Is there an acceptable response rate (60% or above)?
5.1. Is the mixed methods research design relevant to address the qualitative & quantitative research questions (or objectives), or the qualitative & quantitative aspects of the
mixed methods question (or objective)? 5.2. Is the integration of qualitative & quantitative data (or results) relevant to address the research question (objective)? 5.3. Is
appropriate consideration given to the limitations associated with this integration, e.g., the divergence of qualitative & quantitative data (or results) in a triangulation design?
These two items are not considered as double-barrelled items since in mixed methods research, (1) there may be research questions (quantitative research) or research
objectives (qualitative research), & (2) data may be integrated, &/or qualitative findings & quantitative results can be integrated.

266
Table 3-1 Characteristics of the included studies

Stakeholders Author, Year, Study design Participants Interview guidelines/ Main focus and
Country Measurement significant findings
Law Baker LM, Qualitative in- 7 female vice police Questions focused on - Officers saw prostitutes as doing their jobs
enforcement 2005, U.S. depth interview officers (Response attitude toward decoy sex for drugs.
officers rate: 87.5%) work and experience as - The police showed of sadness, empathy, and
decoy prostitutes sympathy for prostitutes. While they also
found prostitutes to be public health problems
or nuisances.
Dodge M, et al., Qualitative semi- 25 female police Officers‘ thoughts, - Officers saw prostitutes as doing their jobs
2004, U.S. structured officers feelings, and behaviours for money (pay drugs/rent).
interview (age: N.A.) about decoy sex work - Prostitutes had been viewed as a victim of
(Response rate: society‘s larger social ills.
N.A.) -All women officers agreed that prostitution
resulted in wide range of victimization, and
caused problems for neighborhoods,
businesses, and homeowners.
Giacopassi DJ, Qualitative 13 Police officers Topics focused on - The vice officers showed sympathy towards
et al., 1991, unstructured (age: N.A.) officers‘ personal beliefs prostitutes and saw these young women as
U.S. interview (Response rate: and their perceptions of pitiable. Elicit an offer from prostitutes was
N.A.) their enforcement duties distasteful.
- The typical vice officers had no illusion about
eliminating prostitution, but believed that
prostitution was harmful to the community and
individuals.
Guinto- Mixed-method Survey: 187 23-item Attitude scale, - The officers admitted that women engaged in
Adviento MLM, study (Cross- policemen developed by author prostitution were there by force of
1988, sectional survey Intensive interview: circumstances.
Philippines with semi- 25 policemen - They showed sympathy and understanding.
structured (Response rate: While the majority of them disapprove the act
intensive N.A.) of prostitution.
interview)

267
 Maguire M, Qualitative Semi- 14 female police Officers‘ experience as a - Officers saw prostitutes as doing their jobs
et al., 2011, U.S. structured officers who were decoy and personal for drugs/money/by force.
interview assigned to work views on prostitution, - Officers expressed negative feelings toward
decoy operations and interactions with the mechanics of sex work, they presented
(age: 27-46) johns on the street empathy, sadness toward sex workers.
(Response rate:
N.A.)
Mentzer H, Cross-sectional 158 Police officers Police officers‘ - Prostitutes were described as ―lower class
2010, U.S. survey (self- (Response rate: perceptions of female person,‖ ―crack whore,‖ and ―many women are
administrated 30.7%) prostitution and addicted to drugs.‖
questionnaire) prostitutes: Prostitution - Disagree with decriminalizing and regulating
Scale, developed by the prostitution: (62.1%),
authors - Agree with legalizing prostitution would
increase social problems: (61.6%),
- Selective toleration when mediating between
prostitutes and the community was the best
policing strategy (88.5%).
Smith M, et al., Cross-sectional 201 Law  Attitude scales - Support for the legalization of prostitution
2015, Bosnia survey (self- enforcement regarding the sex trade (current practitioner 37.3% vs. future
and administered) officers, legal  Misperceptions of practitioner 37.8%);
Herzegovina actors, future human trafficking
practitioners  Attitude toward
(Response rate: criminal justice
N.A.) response
 Attitudes toward
women in the sex
industry
 Attitudes towards
traffickers and attitudes
toward buyers
Professionals in Chan YE, Mixed-method 20 nurse students  Q-sort task - Commercial sex was highly stigmatized, and
health and et al.,2007, study (semi- (age: 21-44y)  Social distance increased social distance
social services Thailand structured one-to- (Response rate:
one interview) N.A.)

268
Jayanna K, et Cross-sectional 131 STI care  Attitudes of care - - 78.8% of care providers believed that sex
al., 2010, India survey (face-to- providers providers toward workers were responsible for spreading HIV
face) (physicians) FSWs, developed by - - 47.0% of them believed that one effective
(Response rate: authors way to prevent HIV was to ban sex work and
70.4%) rehabilitate all sex workers
- - 75.8% of them agreed that all sex workers
should compulsorily undergo HIV testing
Melby V et al., Cross-sectional 479 nurses  Attitudes toward - - 30.7% of the participants believed that
1992, Northern mail survey (Response rate: prostitutes, developed prostitution should be legalized
Ireland 59.9%) by authors - - 66.8% of them believed prostitution was
immoral and 57.3% of them believed that
prostitution was a sin
- - 79.2% of them agreed that prostitutes should
have compulsory medical tests, and 77%
believed that prostitutes should be routinely
tested for HIV
- - 69.9% of them agreed that prostitutes should
be given free condoms to reduce the spread of
HIV
Nakagawa JT, Cross-sectional 292 Medical Attitude toward FSWs - 98.3% of the students either agreed or
et al., 2014, 56 web-based survey students (median with STI symptoms strongly agreed that it would be their job to
Countries age: 23) (Response provide treatment to patients regardless of
rate: 75.1%) occupations and 81.9% of them agreed or
strongly agreed that FSWs comprised a
vulnerable population that deserved particular
attention.
Peled E, et al., Qualitative semi- 13 female CPOs Views held by CPOs - Prostitution was like any other profession,
2013, Israel structured (age: N.A.) toward mothers in while prostitution was dangerous and harmful.
interview (Response rate: prostitution - Prostitution was considered as an acceptable
N.A.) and legitimate occupation.

269
 Peled E, et al., Qualitative in- 15 social workers Social workers - A wide range of views on the reasons women
2015, Israel depth interview (age:24-53) perceptions and attitudes engaged in prostitution (out of choice/by
(Response rate: toward prostitution and force).
75.0%) teenage girl prostitution - They had difficulty in associating the
adolescent girls in their care with prostitution,
and resisted to apply the term ―prostitution‖ to
describe the adolescent girls in their care.
Phrasisombath Cross-sectional 244 health care Attitude toward FSWs - Negative attitudes towards prostitutes with
K, 2012, Laos survey (face-to- providers who with STI symptoms, STI symptoms: pharmacists/drug sellers
face) provide STI developed by authors (68%), medical doctors (59%), nurse/midwives
services (Response (55%), herbalists (53%).
rate: 97.0%)
Rogers SJ, et Cross-sectional 245 staff of health  Stigma measurement - - Negative attitude toward prostitution: 72%
al., 2014, survey (face-to- care and 87 staff of of blame and moral- participants agreed that sex work was
Jamaica and the face) social service driven judgment immoral, and 33% of them believed that it
Bahamas (Response rate: constructs was the women prostitutes who spread HIV.
N.A.)  Series of eight
vignettes
Clients of sex Farley M, 2011, Mixed-method 110 clients of  Illinois rape myth - Reason for sex work: money (73%).
workers Scotland with both prostitutes (age: 18- acceptance scale - Conflict attitudes: 71% stated that
quantitative and 77) (Response rate:  Hostile Masculinity prostitution should be treated like any other
qualitative 100%, completion Scale business, 42% believed that prostitution
measures (fact-to- rate: 63.6%)  Sexual experiences lowered the moral standards of the community.
face) scale - Clients were lack of emotional connection
 46-item Acceptance & and lack of empathy for prostitutes.
justification of
prostitution, developed
by authors
Kennedy MA, Pre-program and 377 men who  Attitudes toward - The program appeared to significantly
2004, Canada post-program attended the British prostitution scale change attitudes towards prostitution, towards
anonymous self- Columbia diversion  Marlowe-Crowne prostituted women, and towards purchasing
report program (age:18- Social desirability sexual services in male clients of prostitutes.
questionnaire 89) (Response rate:  Additional items
84.5%) developed by authors

270
Preston P, et al., Cross-sectional 1343 clients of  Positive attitudes - Whites were most likely to hold liberal
2005, U.S. survey (self- prostitutes toward prostitution, sexual attitudes, Native Americans were more
administered) (Response rate: > developed by authors likely to have positive attitudes towards
80%)  Belief that prostitution prostitution and believed prostitution liked
like their jobs, their jobs.
developed by authors
Potgieter C, Cross-sectional 225 male taxi 22-item questionnaire - Majority (59.6%) of the respondents believed
2012, South survey drivers (age: 26-45) Taxi drivers‘ attitudes girls engaged in sex work for gifts.
Africa (Response rate: and beliefs about taxi - 60.4% believed that girls who slept with taxi
N.A.) queens and their drivers were loose.
relationship with taxi
drivers, developed by
authors
Sawyer S, 1998, Cross-sectional 37 men who were  Prostitution Behaviour - Participants showed contradictory attitudes
U.S. survey (self- arrested for Questionnaire towards prostitution.
administered) patronizing  Minnesota Multiphasic - Agree with the statement: ―Women are
prostitutes (age: 25- Personality Inventory prostitutes because they want to be. It is their
63) (Response rate: (MMPI) choice‖ (34%) ―Prostitutes are victims of
100%)  Minnesota Multiphasic pimps‖ (46%).
Personality Inventory - The participants expressed both support and
(MMPI-2) opposition to legalized prostitution.
Sawyer S, et al., Cross-sectional 140 men who were  14-item Attitudes - Yong clients of sex workers had inaccurate
2001, U.S. survey (self- arrested for alleged toward prostitution and negative beliefs in prostitutes, and less
administered) prostitution use scale (ATPS) supportive of legal support of prostitution
(age: 19-66)  Minnesota Multiphasic than older clients.
(Response rate: Personality Inventory
N.A.) (MMPI-2)

271
 Wortley S, et al., Pre-program 366 clients of  14 statements to - Agree with the statement: ―Most prostitutes
2002, Canada (face-to-face) and prostitutes measure attitudes have a drug problem‖ (pre: 45%, post: 71%)
post-program (Response rate: toward prostitution ―Prostitutes are forced by pimps‖ (pre: 37%,
survey (self- 88.6%)  Knowledge of post: 44%). ―Most prostitutes enjoy what they
administered) Canadian prostitution do for a living‖ (pre: 29%, post: 15%).
law - Clients demonstrated more negative attitudes
 Awareness of dangers towards prostitution at time two than at time
of prostitution one.
 Awareness of the
victims of prostitution
 Anticipated future use
of prostitution ,
developed by the
authors
General public Alikhadzhieva I, Cross-sectional 890 Russian citizen Questionnaire developed -Majority of participants stated that women
2010, Russia survey (age: 16-60) by authors. e.g. engaged in prostitution were saleable, inability
(Response rate:  Attitudes toward to make their way in other areas of the life of
N.A.) people who provide society.
sexual service for a fee - Participants were unwilling to accept legal
 Attitudes toward the regulation of prostitution, and wished to make
customers of the punishment tougher, e.g. 64.2%
commercial sex participants against legalization of prostitution,
 Legalization of and 80% respondents were in favor of methods
prostitution to impose stronger liability.
 The criminalization of
prostitution
Basow SA, et Cross-sectional 89 undergraduate  12- item Attitude - Women and students with profeminist
al., 1990, U.S. survey (self- students (age: not Toward Prostitution attitudes were less acceptant of
administrated) reported) (Response Scale (ATP) decriminalization and legalization of
rate: 100%)  Attitude toward prostitution, and viewed prostitution as
Feminist Scale subordination and exploitation of women.

272
Cao L, et al., Cross-sectional 1000 adult citizens Attitudes toward - Prostitution should never be justified
2010 China data were from (age: 18-65) prostitution with a single (92.6%).
the European (Response rate: item: ―Please tell me
Values Study N.A.) whether you think
Group and World prostitution can always
Values Survey be justified, never be
Association justified, or something in
(2005), face-to- between.‖
face interview)
Cao L, et al., Study 1: 1200 American Attitudes toward - There was a trend toward greater tolerance of
2013, U.S. Longitudinal data (age: ≥18) prostitution with a single prostitution over a 20 year period in the U.S.
were from the (Response rate: item: ―Please tell me
World Values N.A.) whether you think
Surveys (WVS) prostitution can always
and the European be justified, never be
and World Values justified, or something in
Surveys, between.‖
1981/1982, 1990,
1999/2000, face-
to-face interviews

Study 2: Cross-
sectional data
was from the
World Values
Surveys (WVS)
(1999/2000)

273
Chon DS, et al., Secondary data 48,630 public (age: Attitudes toward - The majority of the world population still
2015, 54 analysis (Data 18-85) (Response prostitution with a single perceived that prostitution was never
countries was from the fifth rate: N.A.) item: ―Please tell me justifiable.
wave of World whether you think
Values Survey prostitution can always
(WVS), face-to- be justified, never be
face interview) justified, or something in
between.‖
developed by WVS
Cotton A, et al., Cross-sectional 783 university  6 items from - Endorsement of six prostitution myths: 16-
2002, U.S. anonymous undergraduate Prostitution Behaviour 59%.
survey (self- (age:17-46) Questionnaire - Prostitution myth endorsement was
administered) (Response rate:  Rape myth acceptance significantly correlated with overall rape myth
N.A.) scale - Short form of endorsement
the Illinois Rape myth
Acceptance scale
Jakobsson N, Cross-sectional 1st wave survey: Attitudes toward - Swedes were more negative towards buying
2011, Norway internet-based Total participants: buying/selling sex, sex than Norwegians.
and Sweden survey 3531, including attitudes toward the law
1716 Norwegians on buying/selling sex,
and 1815 Swedes developed by authors
(age: 15-65)
(Response rate:
68.6% among
Norwegians,
60.5% among
Swedes)

274
Kotsadam A, Longitudinal 2nd wave survey Moral attitudes toward - Swedes were significantly more negative
et al., 2011, Internet-based (2009): total prostitution and attitudes toward prostitution than Norwegians.
Norway and survey participants: 2351, toward prostitution law,
Sweden including 1034 developed by the authors
Norwegians
(Response rate:
41.4%), and 1317
Swedes (Response
rate: 43.9%)
Kotsadam A, Longitudinal 3rd wave survey Moral attitudes toward - Social attitudes toward prostitution were
et al., 2014, internet-based (2010): total prostitution, most negative in Sweden, less negative in
Norway and survey participants: 6164 developed by the authors Norway, and least negative in Denmark.
Sweden (overall response - Stigma influenced the demand for sex,
rate: 50.3%), 2088 individual who thought buying sex was
Danes (Response immoral bought less sex.
rate: 46.4%), 1705 - Law did not affect moral attitudes toward
Swedes (Response buying sex.
rate: 52.4%), 2371
Norwegians
(Response rate:
52.7%)
Kuosmanen J, Cross-sectional 1134 Public (age:  Attitudes to the sex - 70.7% of the respondents wanted to retain the
2011, Sweden mail survey 18-74) (Response purchase legislation law of prohibiting the purchase of sex: (79%
rate: 45.4%)  Attitude to any women, 60% men). 58.7% of the respondents
eventual wanted to prohibit the sale of sex.
criminalization of the - The legislation has reduced the demand side
sale of sex of prostitution.
 Personal experiences
of the purchase or sale
of sex, all
questionnaires
developed by authors

275
Long SL, et al., Cross-sectional 266 college  3 items were selected - General attitudes towards prostitution
2012, U.S. survey online students (age: 18- from Attitude toward appeared to be negative.
survey 29) (Response rate: prostitution scale
86.1%)  Marlowe-Crowne
Social Desirability
scale
 Hostility Toward
Woman Scale
May DC, 1998, Cross-sectional 1514 adults (age:  Attitude toward - Prostitution should be legal (18.7%);
U.S. telephone ≧18) (Response legalization of Prostitution should be illegal (75.8%).
interview rate: 74.2%) prostitution,
 Tolerance index
developed by the authors
Moore S, 1999, Cross-sectional 400 general public 20-itme Attitude to - Less than half the respondents approved of
Australia survey (self- (age: 24-49) Prostitution Scale prostitution, while accepted its place in society.
administrated) (Response rate: (ATPS), developed by
N.A.) authors
Morton H, Cross-sectional 239 Undergraduate  14 scenarios to assess - Female and street prostitution were perceived
et al., 2010, survey (self- students (age: ≧18) Knowledge of more negatively than male and indoor
Canada administrated) (Response rate: prostitution laws, prostitution.
N.A.) developed by authors - Legalization of prostitution (42.5%);
 15-items scale: Beliefs Criminalization of prostitution (35.8%); more
about prostitution, social services for those in prostitution
developed by authors (16.7% ); increase the safety for prostitutes
(40%).
Otsuki N, et al., Cross-sectional 1190 Japanese (age: Attitudes regarding the - Tolerance of buying sex: 40.0% (male),
2009, Japan national survey 18-65) (Response Buying and Selling of 30.1% (female).
rate: 23.8%) Sexual Services, - Tolerance of selling sex: 32.2% (male),
developed by authors 22.8% (female).

276
Peracca S, 1998, Qualitative focus 88 general public Topics focus participants‘ - There was a relatively lack of severe or
Thailand group discussion (age: 25-40) views of female lasting social stigma towards FSWs. And many
(Response rate: commercial sex worker, Thais were sympathetic towards FSWs.
N.A.) e.g. ―Would most men - The public held the belief that FSWs might
object to marrying a find a husband.
woman who engaged in
commercial sex work?‖
Pudifin S, et al., Cross-sectional 600 general public Tolerance of prostitution, - The majority of South Africans remained
2012, South survey with mix- (age: 17-83), developed by authors strongly morally opposed to prostitution.
Africa mode (Internet- including 512 - The participants would not support legal
based survey and Internet-based reforms aimed at decriminalizing or legalizing
paper-based survey, 88 paper- prostitution.
survey) based survey
(Response rate:
N.A.)
Räsänen P, et Cross-sectional 1208 Finish 14-item subjective - Acceptance of selling sex: 3.40 (1.33).
al., 2007, internet survey students (age: 18- measures regarding - Acceptance of buying sex: 4.46 (1.34).
Finland (two Finish 30) (Response rate: attitudes towards 1= strongly agree; 5= strongly disagree
universities & N.A.) commercial sex,
three colleges) developed by authors
Roberts R, et Cross-sectional 277 undergraduate Awareness, - Reason for sex work: money (93%), sexuality
al., 2010, UK survey (self- students (Response understanding, (6.5%), desperation (6.1%), personal situation
administrated rate: 87.9%) acceptability, knowledge (8.1%).
questionnaire) of students participation - Awareness of student sex work was
in sex industry, and widespread and considerable understandable
likelihood to participant by the majority.
in the sex industry,
developed by the authors

277
Sagar T, et al., Mixed-method 205 community Topics focused on - Attitude toward sex workers: Sex work was
2013, UK study (Cross- members most community members inevitable (73.2%), sex worker rarely or never
sectional affected by street perspectives of street sex impacted on their quality of life (60%),
mail survey, and sex worker (age: work empathy toward sex workers (46.8%), concern
face-to-face) ≥18y, Response about their safety (57.1%).
rate: 33.5%) - Sex worker should be provided with a safe
space to work away from residential areas.
- People should not allowed to buy/sell sex
(29.8%).
- People should allowed to buy/sell sex
(41.5%).
Shdaimah CS, Mixed-methods 130 residents from Perceptions of - Perception of sex workers as a problem:
2012, U.S. with both three prostitution nuisance, fear of crime, negative impact on
quantitative neighborhoods questionnaire, developed quality of life, and negative impact on property
survey (face-to- (Response rate: by research team value.
face or self- N.A.) - Response to prostitution:
administrated) Jail/fine/class/treatment program.
and field - Punishment for pimps and johns.
observation
Stack S, et al., Cross-sectional 45102 general Attitudes toward - There was strong norm against prostitution
2010, 32 nations (Data were from public (Response prostitution with a single among the Muslims of the world.
the fourth wave of rate: N.A.) item: ―Please tell me
World values whether you think
survey (2004)) prostitution can always
be justified, never be
justified, or something in
between.‖

278
 Valor-Segura I, Cross-sectional 620 Public  The scale of the Legal - The tendency to victim-blame prostitutes was
2011, Spain survey (mean age:26.69) Stance towards greater among people who held a hostile
(Response rate: Prostitution, developed ideology toward women, and favored the
94.1%) by authors prohibition of prostitution.
 Ambivalent sexism
inventory
 Beliefs concerning the
motives and
behaviours of men who
pay for sex
 Victim blaming,
developed by authors
Wamoyi J, et al., Qualitative 46 Young people Topics related to - The practice of transactional sex was widely
2011, Tanzania ethnographic (age: 14-24) and parenting and young accepted among parents and young people.
research design, parents of the people‘s sexual - Most of the male participants believed that
using participant young people of behaviours prohibition of prostitution would lead to rape.
observation, in- this age group (age:
depth interview N.A.)
and focus group (Response rate:
discussion N.A.)
Zheng W, et al., Cross-sectional 212 Chinese (age: Topics focused on - 55% of the respondents hold negative
2011, China survey 18-39) (Response participants views about attitudes towards sex workers and described
rate: 73.0%) sex outside marriage them as immoral, having abnormal behaviours,
low class, lazy, greedy, lacking self-respect and
had simply found a quick way to earn money.
Various Bellis MA, et Cross-sectional 1069 participants, Questions related to - All groups agreed that a managed zone would
stakeholders al., 2007, UK survey (on-line including 50 sex views of a managed improve sex workers‘ safety and reduce
open community worker (age: ≥18y), zone‘s location, benefits, prostitution elsewhere.
meetings, self- 51 business, 179 characteristics, and - Location preference: away from residential
administrated) residents, 789 security measures, views areas and pedestrian
public (Response of businesses in two
rate: N.A.) areas considered to host
a managed zone

279
 Lai Y-y, et al., Qualitative 11 participants, Questions related to - Stakeholders held mixed perceptions toward
2015, Hong individual including 3 views toward sex work, sex worker and legalizations of prostitution
Kong interview residents, 2 social current law relating to - Risks in establishing red light districts: 1)
workers, 2 prostitution, and attitudes deviance amplification, 2) unhealthy market
policemen, 2 towards legalization of forces in the red light districts, 3) not
lawyers, 1 NGO prostitution and red light facilitating police work, 4) views towards land
staff, 1 sex worker) districts use, 5) displacement of crime.
(age: N.A.)
(Response rate:
N.A.)

Abbreviations: N.A.: Not applicable. FSWs: female sex workers

280
Table 3-2 Quality appraisal of selected studies
Qualitative studies/qualitative component of mixed methods studies 0.1 0.2 1.1 1.2 1.3 1.4 Score
Author, year, country
Baker LM, 2005 Y Y Y Y Y Y ****
Dodge M, et al., 2004 Y Y N Y Y UC **
Giacopassi DJ, et al., 1991 Y Y N UC Y Y **
Lai Y-y, et al., 2015 Y Y N Y Y UC **
Maguire M, et al., 2011 Y Y Y Y Y UC ***
Peled E, et al., 2013 Y Y N Y Y Y ***
Peled E, et al., 2015 Y Y Y Y Y Y ****
Peracca S, 1998 Y Y N Y Y UC **
Wamoyi J, et al., 2011 Y Y N Y Y UC **
Quantitative studies/quantitative component of mixed-method 0.1 0.2 4.1 4.2 4.3 4.4 Score
studies
Alikhadzhieva I, 2010 Y Y Y N UC N *
Basow SA, et al., 1990 Y Y Y N Y Y ***
Bellis MA, et al., 2007 Y Y Y N UC UC *
Cao L, et al., 2010 Y Y Y N UC N *
Cao L, et al., 2013 Y Y Y N UC N *
Chon DS, ET AL., 2015 Y Y Y N UC N *
Cotton A, et al., 2002 Y Y Y N Y N **
Jakobsson N, 2011 Y Y Y N UC Y **
Jayanna K, et al., 2010 Y Y Y Y UC Y ***
Kennedy MA, 2008 Y Y Y Y Y Y ****
Kotsadam A, et al., 2011 Y Y Y N UC Y **
Kotsadam A, et al., 2014 Y Y Y N UC Y **
Kuosmanen J, 2010 Y Y Y N UC N *
Long SL, et al., 2012 Y Y Y N Y Y ***
May DC, 1998 Y Y Y N Y Y ***
Melby V et al., 1992 Y Y Y Y N N **
Mentzer H, 2010 Y Y Y N Y N **
Moore S, 1999 Y Y Y N Y N **
Morton H, et al., 2010 Y Y Y N UC N *

281
NakagawaJT, et al., 2014 Y Y Y N Y Y ***
Otsuki N, et al., 2009 Y Y Y N UC N *
Preston P, et al., 2005 Y Y Y N Y Y ***
Phrasisombath K, 2012 Y Y Y Y Y Y ****
Potgieter C, 2012 Y Y Y N UC N *
Pudifin S, et al., 2012 Y Y Y N UC N *
Räsänen P, et al., 2007 Y Y Y N Y N **
Roberts R, et al., 2010 Y Y Y N UC Y **
Rogers SJ, et al., 2014 Y Y Y N Y UC **
Sawyer S, 1998 Y Y Y N Y N **
Sawyer S, et al., 2001 Y Y Y N Y N **
Smith M, et al., 2015 Y Y Y N Y N **
Stack S, et al., 2010 Y Y Y N UC N *
Valor-Segura I, 2011 Y Y Y Y UC Y ***
Wortley S, et al., 2002 Y Y Y Y UC Y ***
Zheng W, et al., 2011 Y N UC Y **
Mixed methods (quantitative component) 0.1 0.2 1.1 1.2 1.3 1.4 4.1 4.2 4.3 4.4 5.1 5.2 5.3
Chan KY, et al, 2007 Y Y Y Y Y N Y N Y UC Y Y Y **
Farley M, 2011 Y Y Y UC Y N Y N Y Y Y Y N **
Guinto-Adviento MLM, 1988 Y Y Y Y Y N Y N Y UC Y Y N **
Sagar T, et al., 2013 Y Y N Y Y N Y N UC UC Y Y Y *
Shdaimah CS, 2012 Y Y N Y Y Y Y N Y UC Y Y Y **
Note: key: Y = Yes; N = No; UC = Unclear; QL = Qualitative study; DS: Quantitative descriptive study; MM: Mixed method study. For score, the higher number of * indicates the better of the
research quality. The lowest score is *, while the highest score is ****.
Items: 0.1. Are there clear qualitative & quantitative research questions (or objectives), or a clear mixed methods question (or objectives)? 0.2. Do the collected data allow address the research
question (objective)? E.g., consider whether the follow-up period is long enough for the outcome to occur (for longitudinal studies or study components). 1.1. Are the sources of qualitative data
(archives, documents, informants, observations) relevant to address the research question (objective)? 1.2. Is the process for analysing qualitative data relevant to address the research question
(objective)? 1.3. Is appropriate consideration given to how findings relate to the context, e.g., the setting, in which the data were collected? 1.4. Is appropriate consideration given to how
findings relate to researchers‘ influence, e.g., through their interactions with participants? 4.1. Is the sampling strategy relevant to address the quantitative research question (quantitative aspect
of the mixed methods question)? 4.2. Is the sample representative of the population understudy? 4.3. Are measurements appropriate (clear origin, or validity known, or st&ard instrument)? 4.4.
Is there an acceptable response rate (60% or above)? 5.1. Is the mixed methods research design relevant to address the qualitative & quantitative research questions (or objectives), or the
qualitative & quantitative aspects of the mixed methods question (or objective)? 5.2. Is the integration of qualitative & quantitative data (or results) relevant to address the research question
(objective)? 5.3. Is appropriate consideration given to the limitations associated with this integration, e.g., the divergence of qualitative & quantitative data (or results) in a triangulation design?
These two items are not considered as double-barrelled items since in mixed methods research, (1) there may be research questions (quantitative research) or research objectives (qualitative
research), & (2) data may be integrated, &/or qualitative findings & quantitative results can be integrated.

282
Table 4-1 Methodology quality appraisal of the included studies
Part I: Qualitative studies: Quality assessment of the studies included according to the CASP tool for qualitative studies
Author, Year, Country 1 2 3 4 5 6 7 8 9 10 Total score
Basnyat I, Nepal, 2015 Y Y N N Y Y Y Y Y Important 7
Beattie TS, et al., India, 2012 Y Y N N N N Y N Y Important 4
Chakrapani V, et al., India, 2009 Y Y N N N N Y Y Y Important 5
Folch C, et al., Spain, 2013 Y Y N N N N C N Y Important 3
Ghimire L, et al., Nepal, 2011 Y Y N C N N Y N Y Important 4
Kimani RN, Kenya, 2014 Y Y Y N N N Y N Y Important 5
Kurtz SP, et al., U.S., 2005 Y Y N N N N Y N Y Important 4
Lafort Y, et al., Mozambique, 2016 Y Y N C N N Y N Y Important 4
Marlow HM, et al., Uganda, 2014 Y Y N C N N C N Y Important 3
Mtetwa S, et al., Zimbabwe, 2013 Y Y N C N N Y N Y Important 4
Ngo A, et al., Vietnam, 2007 Y Y N N N N Y N Y Important 4
Nguyen M-N, et al., Canada, 2008 Y Y N N N N Y N Y Important 4
Phillips R, et al., Canada, 2005 Y Y N N N N C N Y Important 3
Porras C, et al., Guatemala, 2008 Y Y N N Y N Y N Y Important 5
Rosenheck R, et al., Tanzania, 2010 Y Y Y C Y N Y N Y Important 7
Scorgie F, et al., Four African countries, 2013 Y Y Y Y N N Y Y Y Important 7
Smith FM, et al., UK Y Y N C N N Y N Y Important 4
Surratt HL, et al., U.S., 2014 Y Y N C Y N C N Y Important 3
Underhill K, et al., U.S., 2014 Y Y N N Y N Y N Y Important 5
Varga LM, U.S., 2012 Y Y Y N Y N Y Y Y Important 7
Wong W-C, et al., China, 2003 Y Y N N N N C N Y Important 3

Y: Yes; N: No; U: Unclear. Criteria 4 was reverse scored.

Checklist for measuring the qualitative study quality

Items: 1. Was there a clear statement of the aims? 2. Was there a clear statement of the aims of the research? 3. Was the research design appropriate to address the aims of the
research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship
between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is
there a clear statement of findings? 10. How valuable is the research?

283
 Part II. Quantitative studies: Quality assessment of the studies included according to the Pocket Guide to Critical Appraisal for cross-
sectional studies Crombie (1996)
Author, Year, Country 1 2 3 4 5 6 7 8 9 10 11 Total score
Duff P, et al., Canada, 2016 Y Y Y Y U N U U Y Y Y 6
Folch C, et al., Spain, 2013 Y Y Y Y U N Y U Y N Y 6
Ghimire L, et al., Nepal, 2011 Y Y Y Y U N U U Y Y Y 6
Hong Y, et al., China, 2012 Y Y Y Y U N U U Y Y Y 6
Jeal N, et al., UK Y Y Y Y U N Y U N N Y 5
Kimani RN, Kenya, 2014 Y Y Y Y U Y Y Y Y N Y 8
King EJ, et al., Russia, 2013 Y Y Y Y U N U U Y Y Y 6
Kurtz SP, et al., U.S., 2005 Y Y Y Y U N U U N N Y 4
Lafort Y et al., Mozambique, 2016 Y Y Y Y U N U U N Y Y 5
Lazarus L, et al., Canada, 2012 Y Y Y Y U N U U Y Y Y 6
Nguyen M-N, et al., Canada, 2008 Y Y Y Y U N Y U N N Y 4
Philips R, et al., Canada, 2005 Y Y Y Y U N U U N N Y 4
PhrasisombathK, et al., Laos, 2012 Y Y Y N Y N Y U Y Y Y 9
Rosenheck R, et al., Tanzania, 2010 Y Y Y Y U N U U Y Y Y 6
Savva H, South Africa, 2013 Y Y Y Y U N U U Y Y Y 6
Shannon K, et al., Canada, 2005 Y Y Y Y U N U U N N Y 4
Surratt HL, et al., U.S., 2014 Y Y Y Y U N U Y Y N Y 6
Varga LM, U.S., 2012 Y Y Y Y U N U Y Y N Y 6
Wang Y, et al., China, 2011 Y Y Y Y U N Y U Y Y Y 6

Y: Yes; N: No; U: Unclear. Criteria 4 was reverse scored.

Checklist for measuring the quantitative study quality

Items: 1. Did the study address a clearly focused question / issue? 2. Is the research method (study design) appropriate for answering the research question? 3. Is the method
of selection of the subjects (employees, teams, divisions, organizations) clearly described? 4. Could the way the sample was obtained introduce (selection) bias? 5. Was the
sample of subjects representative with regard to the population to which the findings will be referred? 6. Was the sample size based on pre-study considerations of statistical
power? 7. Was a satisfactory response rate achieved (>70%)? 8. Are the measurements (questionnaires) likely to be valid and reliable? 9. Was the statistical significance
assessed? 10. Are confidence intervals given for the main results? 11. Can the results be applied to your organization?

284
Table 4-2 Characteristics of the included study
Author, Aims Study Sampling Participants Type of Main focus and significant findings
Year, design Method health care
Country service
Barriers Facilitators
Basnyat To explore Qualitative Not reported 35 FSWs Health care  Intrapersonal: limitation of health  Interpersonal
I, Nepal, how structural individual (Response (age services information, disclosure concerns networks: women‘s
2015 violence was interviews rate: not range:32- (hided sex worker status), health network served as a
enacted and reported) 45y) care costs, other priorities source of health
experienced in (spending money on family) information, e.g.
the context of  Interpersonal: inaccurate health other sex workers,
health care in information given by their health promoters,
the lives of informal networks educators.
FSWs  Institutional: Anticipated/enacted
stigma and discrimination from
health care providers, e.g. negative
attitudes, unequal treatment, fear
of being judged, lack of
confidentiality, long waiting time,
lack of comprehensive services at
VCT clinics

285
Beattie To understand Qualitative Purposive 302 HIV testing  Intrapersonal: lack of knowledge  Intrapersonal: clear
TS, et al., the barriers to study: Focus sampling participants services about HIV services, denial of HIV understanding of the
India, accessing HIV group method (age range: risk/fatalism, fear of mental health benefits of knowing
2012 care services discussion (Response 18-59y, impact of positive test result one‘s status
across rate: not mean age:  Institutional: discrimination and  Interpersonal: peer
different reported) 30.5y), derogatory comments, denial of educators
typologies of including treatment, diagnosing without accompanying
FSWs and 125 FSWs, examination, ineffective treatment, community
men who have 56 MSM, 6 poor facilities, location with members to
sex with men transgenders hospitals, queuing for HIV services,
(MSM) and , 87 female services in hospital corridors,  Institutional:
transgenders peer counseling facilities, long empathetic and
and to identify educators, distances, charges for ―free‖ caring staff, with a
strategies to 28 male peer services, bribe for ―free‖ services, good understanding
overcome educators long waiting time, quotas at ART of issues facing the
them centers, lack of confidentiality FSW community,
 Community: discrimination by  Community: NGOs
family, neighbours, schools and challenging
government officials discriminatory
behaviours and
bribes, service
located in non-
public settings (e.g.
NGO STI services),
FSW ―exclusive‖
services
 Policy: removal of
charge for ―free‖
services by NGO

286
Chakrapa To understand Qualitative Purposive 19 FSWs Free ART  Intrapersonal: inadequate  Intrapersonal: clear
ni V, et barriers faced study: Focus sampling (age range: knowledge about ART, fatalism of understanding of the
al., India, by FSWs group (Response 21-48y) ART, alcohol consumption, fear of benefits of taking
2009 living with discussion rate: not exposure that they were ―diseased‖ ART , receiving
HIV in and two ken reported) and lost clients and income, sex adequate
accessing free informant work had impact on ability to information about
antiretroviral interviews access and adherence of ART ART and its
treatment  Interpersonal: lack of family benefits,
(ART) support, unmet basic needs, lack of commitment to
provided by confidentiality family member
government  Institutional: negative experience  Interpersonal: Peer
ART centers with health care providers, lack of influence of taking
adequate counseling service at care of themselves
government centers and by NGO  Community: NGO
outreach workers, lack of privacy, supported them
perceived biased treatment of initiate ART
FSWs who were not referred by
NGOs, practical difficulties in
being hospitalized for observation
during ART treatment
 Community: societal-level stigma
and discrimination,
Duff P, et To explore the Cohort study Time- 611FSWs Pap testing  Institutional: poor treatment by
al., barriers to (2010-2013) location (median age: health care staff, limited hours of
Canada, cervical sampling 34.0y, Inter operation, and language barriers
2016 screening (Response quartile
among FSWs rate: not range (IQR)
in Vancouver reported) =28-42y)

287
Folch C, To describe Mixed- Convenience Survey: 400 Health care  Intrapersonal: fear/avoid
et al., the use of method sampling FSWs (mean services discrimination, lack of
Spain, social and study method age: 30.6y) understanding of public health
2013 health service (Cross- (Response Focus group: system functions
of FSWs in sectional rate: 88.3%) 23 FSWs  Institutional: lack of
Catalonia and survey with confidentiality, overload health
explore the focus group care system, language barriers,
barriers these discussion) medical malpractice
women
encountered
when
accessing
these services
Ghimire To explore Mixed- Snowball Survey: 425 Sexual  Intrapersonal: lack of knowledge  Institutional: FSWs
L, et al., FSWs‘ use of method sampling FSWs (age health of sexual health services in NGO preferred to visit
Nepal, sexual health study technique range: 15- services FSWs could not visit different
2011 services and (Cross- based on a 46y) clinics/hospitals during day time, clinics/clinics that
the factors sectional convenience In-depth and they could not afford long were far from their
associated survey with sampling interview: waiting times. Disclosure community
with their use in-depth method 15 FSWs concerns: fear of public exposure
and non-use of interview) (Response (age range: of sex worker, costs
services rate: not 19-42y)  Institutional: unfriendly/indifferent
reported) attitudes of health care providers,
lack of confidence in private
clinics‘ health care providers‘
knowledge and skills, sexual
harassment by male doctors, lack
of proper care from government
hospitals, lack of privacy and
confidentiality, lack of gender
compatibility (FSWs were
reluctant to reveal their problems
to male doctors), long waiting time

288
Hong Y, To understand Cross- Ethnographi 1022 FSWs HIV testing  Intrapersonal: low perceived risks
et al., the HIV sectional c targeted (mean age: services (70%), lack of information about
China, testing among survey sampling 24.9 + 6.7y) where to do HIV testing (47%),
2012 FSWs in strategies lack of time for HIV testing (41%),
China (Response stigma such as fear of others
rate: not knowing their HIV status or the
reported) identity of FSWs
 Community: social stigma
associated with sex worker/HIV
status
Jeal N, et To identify Cross- Direct 71 FSWs Health care Barriers to primary care services:  Institutional: clinic
al., UK, barriers sectional approach (age: >16y) services  Intrapersonal: disclosure concerns: that being located
2004 reducing survey and not disclosing sex worker status close to FSWs‘
access to snowball (62%) place (77%),
health services sampling  Institutional: unavailable doctors had
by street sex method appointment (52%), judgment by appropriate
workers and to (Response staff (45%), stigma from other knowledge of sex
identity rate: 98.6%) patients (37%) work (63%),
current Barriers to sexual health care evening opening
patterns of use services: (75%), a system
 Intrapersonal: fear of being judged without
as a sex worker (22%) appointment (70%),
 Institutional: clinic location (45%), self-obtained swabs
the appointment system (32%), (11%), facility
long waiting time (25%), specifically for sex
discrimination from other patients worker (11%),
(25%) doctors who could
provide an
integrated service
(97%), with
condom provision
(89%)

289
Kimani To investigate Mixed- Purposive 323 sex HIV/STI,  Intrapersonal: disclosure concerns  Confidentiality and
EJ, the factors method sampling workers, and other (fear of public exposure of being a privacy
Kenya, influencing study (Response including reproductive sex worker), lack of awareness of  Non-discrimination
2014 effective (Cross- rate: 84.6%) 109 MSWs, health comprehensive HIV/STI services, by staff
utilization of sectional 214 FSWs services self stigma of being a sex worker  Institutional:
HIV/STI survey with (age: ≧15y)  Institutional: stigma from health distance, effective
comprehensiv key care providers, long distance of communication,
e health informant health centers affordable health
service by sex interview  Community: social stigma care costs
workers in and focus
Nairobi, group
Kenya discussion)
King EJ, To examine Cross- Not reported 139 FSWs HIV testing  Intrapersonal: Disclosure
et al., the extent of sectional (Response (mean age: services concerns: discuss involvement in
Russia, FSWs‘ survey rate: not 28.9y, age sex work with doctors (49%)
2013 perceived reported) range: 19-  Institutional: doctor refused to
stigma and 41y) treat them (31%), doctor refused to
experienced treat injection drug users (51%),
discrimination personally had been refused
in the health medical care (30%), unwilling to
care setting see the doctor when necessary due
to the fear of bad treatment (58%)
 Community: stigma associated
with sex worker/HIV status

290
Kurtz SP, To assess the Mixed- Snowball 586 FSWs Health care  Intrapersonal: awareness of
et al., health and method sampling (age: >18y, services service, drug seeking and use,
U.S., social service study method and median age: street life distraction/sense of time,
2005 needs and the (Cross- chain 38y) mental/emotional stability,
associated sectional referral generalized fear, negative attitudes
barriers to survey with strategies  Institutional: availability,
access among focus group (Response information accessibility,
FSWs discussion) rate: not transportation, legal status
reported) requirement, social stigma,
program staff communication
skills
 Policy: fear of being arrested

291
Lafort Y, To understand Mixed- Respondent 333 FSWs HIV and Dissatisfaction with public services  Institutional:
et al., the barriers to method driven (Cross- sexual and  Institutional: bribe by health separate clinics,
Mozambi HIV and study sampling sectional reproductive providers, bad reception by staff, expand the Night
que, sexual and (Cross- (Response survey: 311 health care lack of privacy and confidentiality, clinic, improve
2016 reproductive sectional rate: not FSWs, services long waiting time, common drugs access to the public
health care for survey with reported) median age: shortage, lack of information and services,
FSWs focus group 23.5y explanation by health providers, comprehensive
discussion) ( Mozambic short consultation time health services, e.g.
an), 30 termination of
(Foreign pregnancy, care for
FSWs); incomplete
focus group miscarriage/abortion
discussion:
22 FSWs,
median age:
36 (full-time
Zimbabwean
), 23 (Full-
time
Mozambican
), 22
(occasional
Mozambican
))
Lazarus To measure Cross- Time-Space 252 FSWs Health care  Community: Occupational sex
L, et al., the prevalence sectional Sampling (Median services work stigma was associated with
Canada, of data drawn method age: 35y, increased likelihood of
2012 occupational from a (Response Inter quartile experiencing barriers to accessing
sex work cohort study rate: not range (IQR): health care services.
stigma and (2006-2008) reported) 25-41y)
model its
association
with barriers
to health
access

292
Marlow To understand Qualitative Not reported 9 FSWs Abortion  Intrapersonal: lack of information  Intrapersonal:
HM, et FSWs study: in- (Response (age: > 18y) services of safe abortion and costs complications due
al., experience depth rate: not  Interpersonal: peer advice of using to unsafe abortion
Uganda, with induced interview reported) herbs for abortion  Interpersonal:
2014 abortion  Institutional: experience of poorly receiving
services or treatment, denial of treatment support/information
post-abortion because of they were sex workers from
care at an or because they were seeking of friends/community
urban clinic in abortion outreach educator,
Uganda women‘s
accompaniment to
the health facility
 Institutional:
confidentiality,
caring and high
quality treatment by
the clinic provider
Mtetwa To explore Qualitative Systematic 38 FSWs HIV  Intrapersonal: internalized shame
S, et al., HIV positive study: focus sampling (age treatment and anxiety about being known to
Zimbabw sex workers‘ group (Response range:18- services be a sex worker, financial and
e, 2013 experience discussion rate: not 48y) logistical barriers, such as
with care reported) consultation fee, ART patients
required more nutritious diets,
travelling time, felt shame or
embarrassment, loss of income due
to travel to clinics
 Institutional: negative attitudes
from health care providers, public
humiliation, fear of being
mistreated, health care staff had
no sense of urgency when doing
their work
 Community: social stigma

293
Ngo A, et To explore Qualitative Snowball 124 FSWs STIs and  Intrapersonal: misunderstanding  Interpersonal: peer
al., health seeking study: in- sampling (age: not HIV testing of STIs, internalized stigma (felt opinion
Vietnam, behaviours for depth method reported) services embarrassment), unaware of VCT  Institutional: FSWs
2007 STIs and HIV interview, (Response services, lack of money preferred visiting
testing among focus group rate: not  Interpersonal: peer opinions private clinics,
FSWs in discussion, reported)  Institutional: anticipated/enacted because of friendly
Vietnam and stigma: afraid of being scolded by staff, less
participant health staff, negative attitudes of discrimination, good
observation health care providers, lack of trust care, proper
of doctors: sex workers believed medicine, no
that doctors prescribed a high dose waiting time, high
of medicines for profits, poor care, change of cure, a
long waiting time, a lack of quick recovery,
privacy and confidentiality privacy and
 Community: stigma attached to confidentiality were
STIs secured, mobile
health service and
provide on-site
service, HIV/STIs
should be labeled as
general clinic rather
than a specific
STI/HIV service
 Policy: consultation
and treatment
should be free or
partially subsidized

294
Nguyen To explore the Mixed- Not reported Survey: Health care  Intrapersonal: lack of health care  Institutional: non-
M-N, et reasons for method (Response 201FSWs services and health services information, judgmental approach
al., which FSWs study rate: 93.1%) (mean age: disclosure concerns (feared of of care givers from
Canada, have consulted (Cross- 31.7+7.8y) health care providers‘ judgment specialized clinics
2008 health care sectional Focus group: and hided sex worker status)
professionals survey with 6 FSWs  Institutional: the time of
Focus group (age: not operation of most health services
discussion reported) did not suit FSWs‘ work
and In-depth schedules mental health services
individual interview: were not readily accessible, or
interviews) 12 FSWs long waiting list to consult a
( mean age: psychologist.
34.3+9.3y)
Phrasiso To describe Cross- Not reported 407 FSWs Reproductiv  Intrapersonal: lack of health
mbathK care seeking sectional (Response (age range: e tract service information (25%), lack of
, et al., behaviour and survey rate: 96.2%) 15-31y) infection money (22%)
Laos, barriers to (RTI) and  Institutional: Long clinic waiting
2012 accessing sexually time (67%), inconvenient location
reproductive transmitted of the clinic (31%), judgmental
tract infection infection attitudes of health care providers
(RTI) and STI (STI) (10%), very bureaucratic
services services procedures to use the services
among FSWs (9%)
in Laos

295
Phillips To explore the Mixed- Purposive Survey: 201 Health care  Intrapersonal: Disclosure  Institutional: caring,
R, et al., health care method sampling female, male services concerns: hiding sex worker status non-judgmental
Canada, experience of study method and  Institutional: enacted stigmatized attitudes of health
2005 female, male (Cross- (Response transgender attitudes from health care care providers,
and sectional rate: not sex workers providers, poor quality of care: services specifically
transgender survey and reported) (mean age: lack of privacy, rushed service for sex workers, 24-
sex workers in qualitative 32y, age environment, health care workers h mobile services,
Canada individual range: 18- were lack of education comprehensive
interviews) 63y) services, such as
Sub-group counseling services
in-depth
interview:
79 female,
male and
transgender
sex workers
(mean age:
34y)
Porras C, To understand Qualitative Snowball 35 FSWs Health care  Intrapersonal: disclosure concerns  Intrapersonal: self
et al., the study: in- sampling (mean age: services (fear of disclosing sex workers care intention,
Guatema reproductive depth method 27y, age status) result of preceding
la, 2008 health and interview (Response range: 18-  Institutional: enacted signs and
health care rate: not 47y) stigma/discrimination from health symptoms
among FSWs reported) care workers, lack of resources:
in Escuintla, lack of medicine, poor quality of
Guatemala care: poor treatment by health
workers, absence of clean
facilities, poor laboratory
facilities, provision of scant
information, lack of provision of
holistic care, long waiting time,
location of clinics made FSWs felt
discriminated against

296
Rosenhe To explore Mixed- Convenience 459 FSWs STIs Barriers  Intrapersonal:
ck R, et treatment method sampling self- treatment  Intrapersonal: fear of being labeled perceived potential
al., seeking study (Response reporting services as a prostitute by peers, society, threats to fertility,
Tanzania, behaviours (Quantitative rate: not experiencing medical personnel, husbands or FSWs did not want
2010 among FSWs baseline data reported) symptoms partners symptom
who adopted of both  Institutional: discomfort with the presentation to
experienced from a vaginal gynecological exam procedures, impede their work
symptoms of cohort study discharge and discomfort by having male a
vaginal (2002-2005) and genital medical provider performed the
discharge or and ulcers within exam
genital ulcers qualitative the past year  Community: social stigma
in Tanzania study with ( mean age: associated with sex worker status
in-depth 27.83+7.36y,
interviews) age range:
14-62y)
Savva H, To examine Secondary Non- 2220 sex Health care  Intrapersonal: internalized stigma,  Institutional:
South the factors analysis of probability workers, services alcohol use/abuse positive attitudes
Africa, associated data from a sampling including 77  Institutional: discrimination and from health care
2013 with the cross- method transgender stigmatization, negative attitudes providers, privacy
utilization and sectional (Response sex worker, or refusal of services due to and confidentiality
satisfaction of study rate: not 98 MSWs, migrant status, bad service or  Community:
health service reported) and 2023 refusal of service, poor quality of support from
by FSWs in FSWs (mean health service, long waiting time, advocacy groups
South Africa age: negative attitudes from health care
30+6.65y) providers, abuse by health
providers
 Policy: illegal status, abuse by
authorities-police, fear of being
arrested

297
Scorgie To understand Qualitative Not reported 136 sex Health care  Intrapersonal: lack of HIV service  Institutional: clinics
F, et female, male study: in- (Response workers, services information, could not affort was specifically for
al., Four and depth rate: not including transport costs or user-fees, high sex workers, good
African transgender interview reported) 106 female users fees attitudes of health
countries sex workers‘ and focus (age range:  Institutional: long waiting time, care providers,
(Kenya, experiences of group 25-35y), 26 medicine shortage, inadequate especially those
Zimbabw seeking public discussion male (age transport to hospitals, negative from private clinics,
e, and private range: 20- attitudes of health care providers, sensitize health
Uganda, health care 36y) and 4 such as abusive and hostile, denial providers to them to
South transgender treatment, referring sex workers the needs of sex
Africa), sex workers unnecessarily, blaming sex workers community
2013 (age range: workers for their illness, violation
25-34y) of privacy
 Community: broader social
discrimination and social isolation
Shannon To evaluate Cross- Random 159 FSWs HIV  Intrapersonal: fear of side effects  Institutional: daily
MK, et the needs of sectional sampling (median age: treatment (72%), home delivery
al., women survey method 39y, age services Institutional: insufficient (75%), extended
Canada, engaged in (Response range: 21- knowledge about the treatment daytime hours
2005 survival sex rate: not 61y) (68%), inability to adhere to daily (74%), daily
work and to reported) medication regimes (48%) delivery at a
assess  Institutional: clinic for both men discrete location on
utilization and and women (42%), inability to the street (52%)
acceptance of make regular medical
highly active appointments (55%)
antiretroviral  Community: Stigma associated
therapy with HIV status (46%)
(HAART)

298
Smith To assess Qualitative Opportunity 9 FSWs (age Drug  Interpersonal: lack of support  Interpersonal: long-
FM, et barriers to study: in- sampling range: 23- addiction  Institutional: discriminatory term relationship
al., UK, effective drug depth (Response 55y) treatment practices across a range of the with one person,
2007 addiction interview rate: not services that are designed to offer who could assist
treatment for reported) support in addressing their drug them during the
FSWs addiction, absence of a drug treatment
comprehensive treatment package process

Surratt To examine Mixed- Targeted 457 FSWs HIV testing  Intrapersonal: substance use  Intrapersonal:
HL, et the factors method sampling ( mean age: and  Institutional: denial of treatment higher sexual risk
al., U.S. associated study: method (42.1+6.4), treatment  Community: social stigma behaviours, housing
with HIV quantitative (Response age range: services associated with HIV status, social stability
testing and part: Data rate: not 18-50y) isolation  Interpersonal:
care among a were drawn reported) higher levels of
population of from a social support,
substance randomized  Institutional: having
using FSWs clinical trial, a regular health care
qualitative provider/clinic,
part: focus insurance coverage
group
discussion

299
Underhill To explore Qualitative Not reported 94 Health care,  Barriers to STI testing:  Intrapersonal: self-
K, et al., health care study: in- (Response participants, STIs and Intrapersonal: misperception of all care intentions
U.S., access, depth rate: not including 47 HIV testing STIs are symptomatic, lack of linked to substance
2014 HIV/STI interview reported) MSWs (age services concern about STIs besides HIV, use treatment,
testing among and focus range: 21- lack of awareness that STIs could perceived risk of
MSWs and group 58y), and 47 increase HIV risk, lack of STI HIV infection, reach
men who have discussion MSM (age testing information health crisis
sex with men range: 21-  Barriers to HIV testing:  Interpersonal: the
(MSM) 70y) Intrapersonal: lack of concern for request of a partner
health during times of severe aware of one‘ sex
substance use, low prioritization of worker behaviour
HIV testing compared to other  Institutional: HIV
needs, perceived low risk of HIV testing offered by
infection, having partners tested providers or
―negative‖ for HIV outreach workers
 Barriers to health care:
Intrapersonal: lack of money, lack
of interest in health care during
times of heavy substance abuse,
fear and anticipated shame of
discovering physical damage due
to long-term substance use
Institutional: clinic location was
far away, unmet health care (e.g.
substance use treatment, mental
health care, primary care,
prescription drug coverage, STI
testing, care for hepatitis C, other
chronic diseases)

300
Varga To examine Mixed- Targeted and 546 FSWs Health care  Intrapersonal: lack of  Intrapersonal: Pain,
LM, the health and method snowball participated services money/insurance, lack of free fear of illness in
U.S., health care study sampling in the survey health services information, fear, general from
2012 utilization (Cross- strategies (age range: felt ashamed to seeking health consequences of
among black sectional (Response 18-53y), 13 care without insurance, drug use drug use, and
FSWs in survey with rate: not FSWs  Institutional: negative particularly fear of
miami, florida Focus group reported) participated experiences, with fear, HIV, receiving
discussion) in focus discrimination, distrust, waiting public benefits (e.g.
group times, and addiction are all receiving social
discussion linked to lack of links and security, disability
(age range: resources, distrust of welfare, public
20-53y) discriminatory health care assistance for food
system stamps), having
depression symptom
 Institutional: good
experience with a
doctor, having a
regular doctor she
trusted, having
transportation,
having insurance
Wang Y, To explore Cohort study Not reported 970 FSWs HIV testing  Intrapersonal: perceived risk for  Intrapersonal: self
et al., factors (January to (Response (age range: services HIV infection care intention
China, associated December rate: 80%) 14-41y)  Community: social stigma  Interpersonal:
2011 with 2007) associated with sex worker and acquaintance and
utilization of a HIV status peer opinion, having
free HIV another FSWs
voluntary HIV accompanied
counseling  Policy level factors:
and testing available free
(VCT) clinic treatment
by FSWs

301
Wong W- To understand Qualitative Chain 89 FSWs Health care Many FSWs tried self-medication or  Institutional:
C China, FSWs study: focus sampling (median age: services private physicians first as they were accessibility: close
2003 medical- group methods Burmese: more user friendly and perceived to to their work place,
seeking discussion (Response 19.4y; have more privacy open late and until
behaviour and rate: not Chinese:  Institutional: no one want a clinic early hours in the
expectations reported) 22.6y) to serve them alone, language morning, clinics to
of sex
FSWs: female the essential barrier
workers; MSWs: male sex workers; VCT: voluntary testing and counseling; STIs: sexually transmitted infections; provide specialist-
components oforganization; ART: antiretroviral therapy
NGO: Non-governmental led
clinical STIs/gynaecology
services in services including
Ruili, China terminations of
pregnancy, insertion
of intrauterine
devices and clinical
psychology,
condoms,
interpretation
services,
confidential access
to HIV testing,
affordable health
care cost
 Policy: affordable
care

302
Table 4-3 Barriers to health services among sex workers
Intrapersonal level barriers Interpersonal level Institutional level barriers Community level barriers Policy level
barriers barriers
Lack of information or knowledge Lack of support Poor quality of care Stigma Illegal status
of diseases/services
Lack of health Lack of family support Negative attitudes from health care providers Sex work-related stigma Illegal status
information/misunderstanding from society
of diseases
Perceived low risk of HIV Domestic violence Poor/unequal treatment HIV/STIs-related stigma Fear of being
infection arrest
Lack of information or Lack of referral clients Denial of treatment Drug use-related stigma:
knowledge of service/treatment from peers
Fear Influence of social Inadequate counseling
networks
Fear of sex work related stigma Health information Sexual harassment by male doctors
from peers
Fear of being infected with Bribe by health care workers
HIV/STIs
Fear of side effects of treatment Lack of privacy and confidentiality
Costs Lack of adequate and convenient services
Cost of health care service Lack of comprehensive services/treatment
Other priority Inconvenient opening hours
Loss of income (27, 34) Long waiting times
Lack of capacity Inconvenient locations
Substance abuse Lack of transportation
Street life Lack of user-friendly appointment systems
Mental/emotional stability Insufficient facilities and resources
Sex work Lack of gender compatibility/discomfort by
having male doctor performed the exam
Hard to adherence of daily Types of clinics
regimes
Clinics served for both gender
Clinics served sex workers alone
Fear of being as sex workers at STI clinics

303
Table 4-4 Facilitators to health services among sex workers
Intrapersonal level facilitators Interpersonal level Institutional level facilitators Community level facilitators Political facilitators
facilitators
Health information Social support High quality service NGO support Health care policy
incentives
Understand benefit Own network Health care providers‘ non-judgmental/ Health information Free service/cost
information positive attitude subsidize
Adequate information Emotional and Health care providers‘ appropriate Emotional support
practical support from knowledge of sex worker or sex industry
peers
Health concerns Family support Confidentiality Financial support
Threats to fertility Broader social High quality of treatment Knowledge of legal and human
support rights
Self care intention Available, accessible, and affordable services Advocating government support
for HIV treatment
Perceived high risk of HIV Comprehensive and integrated services Working for corruption-free
infection health services
Preceding signs and symptoms Convenient opening hours
Commitment to family No waiting time
Others Close to workplace
Don't want symptom affect Far from community
work
Substance use treatment Having transportation
Mobile services/home delivery
User-friendly appointment system)
Interpretation service
Insurance
Affordable price
Less stigmatized clinics
Be labeled as general clinic
FSW exclusive service
Others
Self-obtained swabs
Regular health care provider

304
Table 6-1 Quality appraisal with Downs and Black scale
Author, year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Total Quality
score level
All A.C., 1997 1 1 0 1 0 1 1 0 1 0 0 0 1 0 0 0 1 1 1 1 1 0 0 0 0 1 0 13 Poor
Aeora S., 2014 1 1 0 1 0 1 1 0 1 1 0 0 1 0 0 0 1 1 0 1 1 0 1 0 0 1 0 14 Fair
Balogun J, et al., 1998 1 1 0 1 2 1 1 0 1 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 1 1 0 13 Poor
Bluespruce J., et al., 2001 1 1 1 1 2 1 0 0 1 1 1 1 1 0 0 0 1 1 1 0 0 1 0 0 1 1 0 18 Fair
Britton P, et al., 1999 1 1 0 1 0 1 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 0 0 0 0 0 0 13 Poor
Buskin, S.E., et al., 2002 1 1 0 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 1 0 10 Poor
Carney J.S., et al., 1999 1 1 0 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 0 0 0 0 0 0 10 Poor
Charuluxananan S. et al., 1 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 1 1 1 0 1 1 0 0 0 1 0 13 Poor
2000
Chisholm M, et al., 1999 1 1 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 1 1 1 1 0 0 0 0 1 0 16 Fair
Collins P.Y., et al., 2006 1 1 0 1 0 1 1 0 1 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 1 0 12 Poor
Diesel Holly, et al., 2013 1 1 1 1 2 1 1 0 0 1 1 1 1 0 0 0 1 1 0 1 1 1 0 0 0 0 0 17 Fair
Ezedinachi E., et al., 2002 1 1 1 1 2 1 1 0 0 1 1 0 1 0 0 0 1 1 1 1 0 0 1 0 1 0 0 17 Fair
Geibel S. et al., 2017 1 1 1 1 2 1 1 0 0 1 0 0 1 0 0 0 1 1 1 0 1 1 0 0 1 0 0 16 Fair
Gross E. J., et al., 1993 1 1 0 1 0 1 1 0 0 0 0 0 1 0 0 0 1 1 1 0 1 1 0 0 0 1 0 12 Poor
Gutierrez J.M.M., 2014 1 1 1 1 0 1 1 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 0 0 0 1 0 17 Fair
Held SL, et al., 1992 1 1 1 1 0 1 1 0 1 0 1 1 0 0 0 0 1 1 0 1 1 0 1 0 0 1 0 15 Fair
Kamiru HN, et al., 2009 1 1 1 1 2 1 1 0 1 1 0 0 1 0 0 0 1 1 1 1 1 0 0 0 0 1 0 17 Fair
Kaponda C.P.N., et al, 2009 1 1 1 1 2 1 1 0 0 1 1 0 1 0 0 0 1 1 1 0 1 0 0 0 0 0 0 15 Fair
Kemppamen J.K., et al., 1 1 0 1 0 1 0 0 1 1 0 0 1 0 0 0 1 1 1 0 1 0 1 0 0 1 0 13 Poor
1996
Lewis D.A., et al., 1996 1 1 0 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 1 0 0 0 0 0 0 9 Poor
Li L, et al., 2013 1 1 1 1 2 1 1 0 0 1 1 1 1 0 0 0 1 1 1 1 0 0 0 0 1 0 0 17 Fair
Lohiniva A.L, et al., 2015 1 1 1 1 2 1 1 0 0 1 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 14 Fair
Lueveswanij S., et al., 1 1 1 1 2 1 1 0 0 1 0 0 1 0 0 0 1 1 1 0 0 0 0 0 1 1 0 15 Fair
2000
Mak W.W.S, et al., 2015 1 1 1 1 0 1 1 0 0 0 0 0 1 1 0 0 1 1 0 1 1 0 1 0 0 0 0 13 Poor
Mahendra V.S., et al., 2006 1 1 0 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 8 Poor
McCann T.V., et al., 1998 1 0 1 1 2 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 0 0 0 0 1 0 13 Poor
Mockiene V., et al., 2011 1 1 1 1 2 1 1 0 1 1 1 0 1 0 0 0 1 1 0 1 0 1 1 0 0 1 1 19 Good
Nanayakkara G et al., 2017 1 1 0 1 2 1 1 0 1 1 0 0 1 0 0 0 1 1 1 1 1 1 1 0 0 1 0 16 Fair
Operario D., et al., 2016 1 1 0 1 0 1 1 0 1 1 0 0 1 0 0 0 1 1 1 1 0 1 1 0 0 1 0 15 Fair
Orlander Jay, et al., 1994 1 1 0 1 0 1 1 0 0 1 0 0 1 0 0 0 1 1 1 1 0 1 0 0 0 0 0 12 Poor
Pisal H., et al., 2007 1 1 0 1 0 1 1 0 0 1 0 0 1 0 0 0 1 1 1 0 1 0 0 0 0 0 0 11 Poor
Pulerwitz J., et al., 2015 1 1 1 1 0 1 1 0 1 1 1 1 1 0 0 0 1 1 1 0 0 1 0 0 0 1 0 16 Fair

305
 Author, year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Total Quality
score level
Shah S.M., et al., 2014 1 1 0 1 0 1 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 1 0 17 Fair
Stewart K.E., et al., 1999 1 1 0 1 0 1 0 0 1 1 0 0 1 0 0 0 1 1 0 1 1 0 1 0 0 1 0 13 Poor
Stiernborg, M., et al., , 1 1 0 1 0 1 1 0 0 0 0 0 1 0 0 0 1 1 0 1 1 0 0 0 0 1 0 11 Poor
1996
Uwakwe C.B.U, et al., 1 1 0 1 0 1 0 0 0 1 0 0 1 0 0 0 1 1 0 1 1 0 0 0 0 0 0 10 Poor
2000
Uys L., et al., 2009 1 1 0 1 0 1 1 0 0 1 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 11 Poor
Valois P., et al., 2001 1 1 0 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 9 Poor
Varas-Diaz N., et al., 2013 1 1 1 1 2 1 1 0 0 1 0 0 1 0 0 0 1 1 0 1 1 1 1 0 0 0 0 16 Fair
Wang Debin, et al., 2009 1 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 1 0 0 0 0 1 0 11 Poor
Williams A.B., et al., 2006 1 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 11 Poor
Wu S, et al., 2008 1 1 1 1 2 1 1 0 1 1 0 0 1 0 0 0 1 1 0 0 0 1 1 0 0 1 0 16 Fair
Wu Z.Y, et al., 2002 1 1 0 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 1 0 0 0 1 0 0 0 0 11 Poor
Yiu J.W., et al., 2010 1 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 1 1 0 1 0 1 1 0 0 1 0 13 Poor
Young , et al., 1989 1 1 0 1 0 1 1 0 0 1 0 0 1 0 0 0 1 1 1 0 1 0 0 0 0 0 0 11 Poor

Quality levels: excellent (24 to 28), good (19 to 23), fair (14 to 18), and poor (less than 14)

Checklist for measuring the study quality

Reporting
1) Is the hypothesis/aim/objective of the study clearly described?
2) Are the main outcomes to be measured clearly described in the Introduction or Methods section?
3) Are the characteristics of the patients included in the study clearly described?
4) Are the interventions of interest clearly described?
*5) Are the distributions of principal confounders in each group of subjects to be compared clearly described?
6) Are the main findings of the study clearly described?
7) Does the study provide estimates of the random variability in the data for the main outcomes?
8) Have all important adverse events that may be a consequence of the intervention been reported?
9) Have the characteristics of patients lost to follow-up been described?
10) Have actual probability values been reported?
External validity
11) Were the subjects asked to participate in the study representative of the entire population from which they were recruited?
12) Were those subjects who were prepared to participate representative of the entire population from which they were recruited?
13) Were the staff, places, and facilities where the patients were treated, representative of the treatment the majority of patients receive?

306
 Internal validity - Bias
14) Was an attempt made to blind study subjects to the
15) Was an attempt made to blind those measuring the main outcomes of the intervention?
16) If any of the results of the study were based on ―data dredging‖, was this made clear?
17) In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients?
18) Were the statistical tests used to assess the main outcomes appropriate?
19) Was compliance with the interventions reliable?
20) Were the main outcome measures used accurate (valid and reliable)?
Internal validity – Confounding (selection bias)
21) Were the patients in different intervention groups (trials and cohort studies) recruited from the same population?
22) Were study subjects in different intervention groups (trials and cohort studies) recruited over the same period of time?
23) Were study subjects randomised to intervention groups?
24) Was the randomised intervention assignment concealed from both patients and health care staff until recruitment was complete and irrevocable?
25) Was there adequate adjustment for confounding in the analyses from which the main findings were drawn?
26) Were losses of patients to follow-up taken into account?
27) Did the study have sufficient power to detect a clinically important effect?

Yes: 1, no: 0, unable to determine: 0

*Item 5: Yes: 2, partially: 1, no:0

307
Table 6-2 Characteristics of the included study
Study Participants
Author, year, Aims of the study Settings Study design Participants Age (years) Sample size Loss to Inclusion
country Mean (SD) follow- criteria
up %
All A.C., et al., To assess the University QE/NC Nursing NS 39 0.0% Junior and senior
1997, U.S. effectiveness of students nursing students
HIV/AIDS education
on the anxiety of
nursing students.
Arora S., et al., To assess the College of RCT Female 17.5 65 0.0% Nursing student
2014, India effectiveness of an nursing nursing pursuing third
empowering students year BSC and
programme on student third year
nurses‘ understanding general nursing
and beliefs related to
HIV/AIDS.
Balogun J, et al., To assess the University QE/C Physical 19-41 49 NS Physical
1998, U.S. effectiveness of therapist therapist and
professional education (PT) and occupational
on the knowledge and occupational therapist
attitudes of physical therapist students
therapist and (OT) admitted during
occupational therapist the 1994-1995
students towards AIDS. academic year.
Bluespruce J., et To examine the Primary care QE/NC Primary care 47 49 4.0% All providers in
al., 2001, U.S. effectiveness of an clinics clinics the two clinics
intervention in providers who have
changing factors that opportunities for
influence providers‘ HIV risk
HIV risk assessment assessment and
and counseling counseling as
behaviours. part of their
clinical roles.

308
Britton P, et al., To assess the University; QE/NC Medical ≧20 122 51.6% NS
1999, U.S effectiveness of department of professionals
HIV/AIDS educational public health and medical
campaign on health students
professionals‘
knowledge and attitudes
toward HIV/AIDS.
Buskin, SE, et al., To examine the University QE/NC Counselor NS 122 51.6% NS
2002, China. effectiveness of an education
intensive model of students
training in HIV
counseling for
counselor education
students.
Carney JS, et al., To evaluate the impact Tertiary QE/C Nursing >18 60 3.33% NS
1999, U.S. of a specialized course education students
to train baccalaureate institutes
nursing students to
work with individuals
with HIV disease.
Charuluxananan To assess the Hospital QE/NC Anesthesiolo NS 177 9.2% NS
S. et al., 2000, effectiveness of short with gists and (post
Thailand course educational repeated nurse test):
program on knowledge, measures anesthetists 34.5% (4-
attitudes and behaviour month
among anesthesia follow
personnel. up)

309
Chisholm M, et To assess the University QE/NC First year NS 295 1.7% First year
al., 1999, U.S. effectiveness of an pharmacy pharmacy
HIV/AIDS intervention students students
program in improving
first-year pharmacy
students‘ attitudes
toward providing care
to HIV positive and/or
AIDS patients.
Collins P.Y., et To assess the Three public QE/NC Mental 39 (8.68) 44 4.5% NS
al., 2006, South effectiveness of mental health health
Africa workshop on mental facilities providers
health providers‘
knowledge and anxiety
about AIDS.
Diesel H, et al., To evaluate the College of QE/C Nursing 20-36 33 21.2% Senior level
2013, U.S. effectiveness of an nursing students in a nursing students
educational intervention bachelors‘
on student nurses‘ degree
knowledge, attitudes, program
and beliefs of
HIV/AIDS among
senior-level nursing
students.
Ezedinachi E, et To assess the Hospitals QE/C Health care Intervention 1552 Interventi NS
al., 2002, Nigeria effectiveness of workers group: 36.12 on group:
intervention on health (8.34) 1072,
workers‘ HIV/AIDS Control control
attitudes and group: 34.11 group:
knowledge. (7.48) 480)
drop out:
NS)

310
Geibel S. et al., To assess the Health service QE/NC Health care 26-39 300, NS
2017, Bangladesh effectiveness of a facilities providers 75.0%
stigma reduction
training program for
service providers
attitudes toward young
marginalized people
and young client
satisfaction with
services
Gross E.J., et al., To evaluate the Schools QE/NC School NS 218 6.0% NS
1993, U.S. effectiveness of a day- nurses
long educational
program on knowledge,
attitudes, and practice
of school nurses.
Gutierrez J.M.M., To assess the Hospital QE/NC Nurses NS 58 0.0% Nurses who
2014, Saudi effectiveness of encountered
Arabia HIV/AIDS educational patients with
intervention on stigma HIV/AIDS, had
reduction among no formal
nurses. HIV/AIDS
training, were
employed for 6
months or
above, and
currently
working at the
time of survey.

311
Held SL, et al., To determine the University RCT Undergradua 20-35 103 3.9% Entry level
1992, U.S. effectiveness of an te junior undergraduate
education unit on physical junior physical
physical therapy therapy therapy students.
students‘ knowledge, students
attitudes, and
willingness to treat
patient with AIDS.
Kamiru HN, et To assess the Hotel QE/NC Health care NS 101, 0.0% NS
al., 2009, effectiveness of a providers
Swaziland training program to
increase the capacity of
health care providers to
provide HIV/AIDS care
and treatment
Kaponda CPN, et To assess the Hospitals QE/NC, Intervention: % over 35y Participation: NS All hospital
al, 2009, Malawi effectiveness of peer- hospital (Baseline: 855 workers,
group intervention on cross- workers 57.5%; post- including both
the HIV-related sectional intervention: Evaluation: clinical and non-
knowledge, attitudes, survey Evaluation 58.9%) Baseline (n = clinical staff.
and personal behaviours hospital 366);
of the hospital workers. workers: Post-
intervention
(n = 561)

Kemppamen J.K., To assess the Hospital RCT with Nurses ≧30 42 14.3% Licensed
et al., 1996, U.S. effectiveness of repeated professional
different approaches to measures nurses
increase nurses‘
willingness to provide
care for people living
with HIV/AIDS.

312
Lewis DA, et al., To assess the Family health QE/NC Dentists, ≧18 29 65.5% NS
1996, UK effectiveness of the services with dental
workshop on dental authority repeated nurses, and
team‘s knowledge, measures hygienists
attitudes and behaviours
toward caring for
people living with
HIV/AIDS
Li L, et al., 2013, To assess the Hospitals RCT with Health Intervention 1760 0.3% 1) Staff who
China effectiveness of the repeated service group: 37.44 (Intervention had regular
intervention on service measures providers control group: 880, contact with
providers‘ stigmatizing group: 38.74 control group: patients,
attitudes and behaviours 880) including
toward people living doctors,
with HIV/AIDS. nurses, and
lab
technicians.
2) Aged 18
years or
above.
Lohiniva A.L., et To evaluate the Hospitals QE/C Physicians ≧20 347 NS Physicians and
al., 2015, Egypt effectiveness of stigma- and nurses (Intervention nurses in the
reduction intervention group: 203, surgical units.
in a health care setting. control group:
144)
Lueveswanij S., To evaluate the Dental clinics QE/C Oral health Intervention 149, 6.7% NS
et al., 2000, effectiveness of an professionals group: < 30
Thailand educational (55.7%),
intervention in control
improving Thai oral group <30
health personnel‘s (61.9%)
knowledge, attitudes
and practices regarding
HIV/AIDS.

313
Mak WWS, et al., To evaluate the Tertiary RCT Students of NS 88 NS Participants who
2015, Hong Kong effectiveness of a game- institutions health- were
based experiential related undertaking
approach in reducing program health-care
HIV-related stigma professional
among health-care programs.
professionals
Mahendra V.S., et To evaluate the Hospitals QE/NC, Health care NS n=1769, NS NS
al., 2006, India effectiveness of cross- workers baseline:
intervention on stigma sectional n=884, after
and discrimination in study intervention:
participating hospitals. n=885

McCann TV, et To evaluate the University QE/NC Nurses ≦24 (23.0%) 74 12.2% Registered
al., 1998, effectiveness of 25-44 nurses who
Australia educational intervention (77.0%) enrolled in the
among registered nurses Bachelor of
on caring of patients Nursing course.
who have HIV/AIDS.
Mockiene V, et To evaluate the Hospitals RCT Nurses 43.1 (8.8) 206 10.0% NS
al., 2011, effectiveness of an
Lithuania educational intervention
on nurses‘ HIV-related
knowledge and
attitudes.
Nanayakkara G et To evaluate the National RCT Second year 20-26 129, 0.0% Second year
al., 2017, effectiveness of AIDS school of nursing (intervention nursing students
SriLanka education program on nursing students group: 65,
nursing students‘ AIDS control group:
knowledge and 64)
attitudes.

314
Operario D, et al., To assess the Hospitals Cluster Physicians NS 249 11.2% NS
2016, China effectiveness of a RCT with and
knowledge-based and repeated patients
skills –based program measures
for physicians in china
to reduce patients‘ STI
risk.
Orlander J, et al., To assess the Hospital QE/C Second and NS 41 24.0% Second and third
1994, U.S. effectiveness of a third year (intervention year medical
weekly outpatient clinic medical group:21, residents
on medical residents‘ residents control group:
attitudes toward 20)
PLWHA.
Pisal H, et al., To assess the Hospital QE/NC Nurses >40 (71%) n=552 32.8% NS
2007, India effectiveness of a short
HIV/AIDS health
education program on
knowledge and attitudes
of nurses in a
governmental hospital.
Pulerwitz J, et al., To evaluate the effect of Hospital QE/C, Hospital 38.7 (0.34) 1592, NS NS
2015, Vietnam two interventions on workers, Baseline:
HIV stigma among Cross- including n=795, post-
hospital workers. sectional doctors, intervention:
survey nurses, ward n=797
staff,
administratio
n and
support staff
Shah SM, et al., To assess the College QE/C Nursing 18-29 88 0% Second year
2014, India acceptability and students undergraduate
feasibility of a brief nursing students
HIV stigma reduction
curriculum among
nursing students.

315
Stewart KE, et To compare the University RCT with Nurses 40.8 (9.81) 88 18.2% NS
al., 1999, UK effectiveness of a medical centre repeated
didactic programme and measures
with an SCT-based surrounding
program on practicing hospitals
nurses‘ knowledge,
attitudes and comfort in
provi ding care for
people living with HIV.
Stiernborg, M, et To compare the Colleges QE/C Nursing 17-41 643 (didactic 12.6% NS
al., , 1996, effectiveness of a students group: 182,
Philippines didactic programme experiential
with experiential group: 185,
learning on nursing control group:
student‘s AIDS-related 195)
knowledge and
attitudes.
Uwakwe C.B.U, To examine the changes University QE/C Nurses 27-52 141 NS Registered
et al., 2000, in nurses‘ attitudes and (Intervention nurses pursuing
Nigeria perceptions of AIDS group: 68, the BSc Nursing
accruing from a control group: programme.
systematized 73)
HIV/AIDS education
programme.
Uys L, et al., To explore the Health care QE/C Setting 37.9 (8.8) Setting nurses NS NS
2009, Lesotho, effectiveness of an HIV settings nurses (n=134)
Malawi, South stigma intervention in Team nurses Team nurses
Africa, five African health care People (n=43)
Swaziland, settings. living with People living
Tanzania HIV with HIV
(n=41),

316
Valois P, et al., To assess the Colleges QE/C Nursing Intervention 74 NS All nursing
2001, Canada effectiveness of a students group: 25 (Intervention students from
persuasive strategy on Control group: 27, two colleges
nurses‘ beliefs and group: 23 control group:
attitudes toward 47)
providing care to
people living with
HIV/AIDS
Varas-Diaz N, et To test the efficacy of Medical RCT Medical NS 507 24.0% NS
al., 2013, Puerto an HIV stigma schools students
Rico reduction intervention
with medical students.
Wang Debin, et To assess the feasibility Hospital QE/NC Physicians NS Physician: 69 1.4% Physician: Three
al., 2009, China of the program in and patients years clinical
changing physician‘s Cross- Patients: experience and
HIV/STI knowledge sectional baseline previous work
and skills. survey n=242, post with HIV/STI
intervention: patients.
n=287 Patients: 18-45
years old,
residing in the
local county, and
receiving care
from a
participating
physician.
Williams A.B, et To examine the effect of Hospitals QE/NC Nurses 23-63 208 NS
al., 2006, China a multifaceted
HIV/AIDS educational
intervention on the
knowledge, attitudes
and willingness of
Chinese nurses in
caring for patients with
HIV.

317
Wu S, et al., To assess the Hospitals Cluster Service 35.4 (7. 138 3.0% NS
2008, China effectiveness of a brief RCT providers 97)
intervention on (i.e. doctors, Intervention
reducing HIV-related nurses, and group: 35.9
stigma among service lab (8.41)
providers in China. technicians) Control
group: 35.0
(7.53)
Wu Z.Y, et al., To evaluate a training- Hospitals QE/C, Workshop 1129
2002, China of trainers strategy to training:
update HIV/AIDS Cross- Health
knowledge and attitudes sectional professionals
and behaviour among survey
health professionals and
the public.
Yiu J.W., et al., To compare the University RCT Nursing 20.8 (1.43) 89 0.0% NS
2010, Hong Kong effectiveness of an students
AIDS knowledge-only
program with a
combined program of
AIDS knowledge and
contact with people
having HIV/AIDS in
reducing nursing
students stigma and in
enhancing their
emotional competence
to search these patients.
Young E, et al., To assess the NS QE/NC Nurses NS 200 71.5% Nurses from
1989, U.S. effectiveness of an all- rural areas
day AIDS workshop on
nurses‘ knowledge and
attitudes toward AIDS
and homosexuality.
a
Study design abbreviation: QE/NC: Quasi-experimental with no control group; QE/C: Quasi-experimental with control group; RCT: Randomized controlled trial

318
b
Interventions type abbreviation: I: Information based; SB: Skills building; CS: Counseling/support; C: Contact with affected groups; B: Biomedical strategies; S: Structural
strategies.
HIV: human immunodeficiency virus; AIDS: Acquired Immune Deficiency Syndrome; PLWHA: People living with HIV/AIDS; STIs: sexually transmitted infections; PLHIV:
People living with HIV; NS: Not specified

319
 Table 6-3 Characteristics of interventions
Author, Intervention typeb Dosage of Facilitators of the Measurement Main findings
publication year, Contents of intervention Intervention intervention,
country Theoretical framework (No. of sessions, approaches of the
time of each intervention,
session, the facilitator
duration of
intervention, and
the length of follow
up)
All A.C., et al., I An educational Didactic lectures Attitudes (Validated) - Participants anxiety levels
1997, U.S. - Intervention focused on presentation; Facilitator: NS - Affective component about HIV/AIDS was
information related to HIV/AIDS, The State-Trait Anxiety reduced (p<.05).
nursing process in caring for these assessed at pre- and Inventory (STAI) (20
clients and case management post-intervention. items)

Arora S., et al., I 5 days; Didactic lecture, Knowledge (Validated) - The empowerment program
2014, India - Experimental group vs. control group discussion, - HIV/AIDS-related significantly improved
group assessed at the role-play, case based knowledge (52 items) students nurses‘
- Intervention focused on baseline and 1- scenarios. Attitudes (Validated) understanding (t=3.5,
knowledge of HIV/AIDS, beliefs month follow up. Facilitator: Eight - Beliefs towards p<.001) and belief about
of students about HIV/AIDS, experts from HIV/AIDS (33 items) HIV/AIDs (t=2.7, p<.01).
correct information about AIDS. community medicine
and nursing field

320
Balogun J, et al., I 5 hours seminar Lecture, case study, Knowledge (Invalidated) - Students in both disciplines
1998, U.S. Physical therapist vs. occupational + 5 hours lectures on group discussion, - Knowledge of showed improvement in
therapist medical sciences + audiovisual tapes. HIV/AIDS (34 items) knowledge about AIDS
- The intervention included 5 hours 10 hours lectures; Delivery: physicians Attitudes (Invalidated) (14.3% for PT students and
AIDS education seminar, 5 hours - Attitudes toward 13.8% for OT students)
lectures on medical sciences, and Seminar for PT AIDS (35 items) - Students in both disciplines
10 hours lectures on HIV/AIDS students (junior Behaviour (Invalidated) showed improvement in
related topics for two disciplines, year), and for OT - Willingness to attitudes toward AIDS
respectively. (senior year). provide care (5 (7.4% for PT students and
- OT received additional items) 5% for OT students)
information about psychological Assessed at baseline, - There is no change in
aspects, patients‘ confidentiality, after AIDS students‘ willingness to
and hospice care; education seminar, provide service for PLHIV.
- PT received additional end of professional
information about ethical and education program.
legal issues, psychosocial aspects
of the disease.

Bluespruce J., et I, CS 10-hour training and Role plays, case Knowledge (Invalidated) - The intervention
al., 2001, U.S. - The content of the intervention four hours stories, meetings, - Knowledge of significantly improved
included HIV related knowledge reinforcement. written materials HIV/AIDS (6 items) participants‘ HIV/AIDS-
and prevention, counseling skills Assessed at baseline, Delivery: NS Attitudes (Invalidated) related knowledge,
building 7 months after the - Attitudes/beliefs (6 attitudes, confidence and
- Train the HIV prevention opinion intervention items) comfort with HIV risk
leaders (Team resource assessment and counseling
representatives) Self-efficacy at 7-month follow up (all
- Conceptual framework: Green - Confidence in and p<.05).
and Kreuter‘s comfort with HIV
PRECEDE/PROCEED model risk assessment and
counseling (self-
efficacy) (12 items)

321
Britton P, et al., I, CS, C Two consecutive Lectures, family Knowledge (Validated) - The intervention
1999, U.S. - The content of the intervention weekends for 2 sculpting, - Knowledge regarding significantly improved
focused on ethical, legal and quarter hours during individual/group HIV/AIDS (4 items) participants‘ knowledge,
professional issues: medical the winter quarter or counseling Attitudes (Validated) comfort, willingness, and
aspects of HIV, counseling a daily weeklong simulations Affective component skills level with people
diverse population, contact with course (3 semester Delivery: NS - Comfort with HIV affected by HIV/AIDS at
people living with HIV/AIDS, hours) patients (2 items) post training, and follow up
individual/group counseling Skills (all p<.05).
simulations Assessed at the - Skills to counsel (3
baseline, post items)
intervention, and 10- Behaviour (Validated)
46 months follow-up - Willingness to work
with HIV patients (3
items)
Buskin, SE, et al., I Two HIV/AIDS Didactic lecture Knowledge (Invalidated) - The lecture significantly
2002, China - Intervention focused on lectures; Facilitator: Public - Knowledge of HIV improved HIV related
HIV/AIDS-related information, health officer (11 items) knowledge (p<.001) and
HIV prevention. assess at pre- and Behaviour (Invalidated) attitudes toward providing
post-intervention. - Attitudes about services to HIV patients
willingness to (p<0.001).
provide service for
person infected with
HIV
Carney JS, et al., I 10 weeks HIV/AIDS Didactic lecture, Knowledge (Validated) - The intervention
1999, U.S. - Intervention group vs. control specialized course; discussion, case - HIV/AIDS significantly improved
group presentation knowledge Inventory participants‘ knowledge
- The intervention focused on assessed at the Delivery: NS (25 items) (Carney et (p<.001) and attitudes
HIV/AIDS related knowledge, baseline and 1 week al., 1994) (p<.001) toward
medical treatment, consideration after the Attitudes (Validated) HIV/AIDS.
of psychosocial issues, legal and intervention. - AIDS Attitude Scale
ethical concerns, and societal (54 items) (Shrum et
stigma. al., 1989)

322
Charuluxananan S. I 2 days; Didactic lectures, Knowledge (Invalidated) - The short course
et al., 2000, - Intervention focused on HIV- panel discussion, - HIV related significantly improved
Thailand related knowledge and treatment. Knowledge and symposium and knowledge; some knowledge about HIV
attitudes were small group - attitudes (12 items) (p<.001), partially change
assessed at baseline, discussion Attitudes (Invalidated) attitude (p<.05), but cannot
post intervention, Facilitator: - Attitudes toward change behaviour.
and the behaviour University, Ministry AIDS (5 items)
was assessed at 4 of Public Health, Behaviour (Invalidated)
months follow up. Thai Red Cross - Translated behaviour
Society during anesthesia
practice (8 items)
- Disinfection or
sterilization of
laryngoscope blades
(5 items)
Chisholm M, et al., C 3-hour; Presentation Attitudes (Validated) - The interventions
1999, U.S. - The intervention focused on the Assessed at the Delivery: people - HIV/AIDS Attitude significantly improved
experience of being a HIV baseline, post living with HIV Scale for Pharmacy students attitudes toward
positive intervention. Students (HAS-PS) caring for people living
(18 items) with HIV/AIDS (p=.001)
Collins P.Y., et al., I, SB Nine-session Risk assessment, Knowledge (Validated) - There was a significant
2006, South Africa - The intervention focused on HIV- intervention, role-play, modeling, - HIV-related increase in reported levels
related knowledge, HIV 1.5 days; problem-solving knowledge (17 items) of comfort with HIV care
prevention, skills for techniques Attitudes (p<.05) (effect size d=.54),
communicating with patients, assessed at pre- and Delivery: The Affective component - There was a significant
human rights, discussion of post-intervention. research team - Comfort with AIDS increase in perceived
stigmatization and discrimination, members and local patients (6 items) knowledge of HIV (p<.001)
and staff support medical and legal (effect size d=1.17),
Theoretical framework: social experts - There was a significant
cognitive theory increase in reported factual
knowledge (p<.001) (effect
size d=.74)

323
Diesel H, et al., I, C 3-hour/week, Discussion, lecture, Knowledge (Validated) - There was no statistically
2013, U.S. Traditional group vs immersion group 7-week elective media, student - The AIDS significant difference
- Traditional group received course course projects, Knowledge Scale between groups in any of
training: focused on providing an presentations, short (AKS) (24 items) the outcomes (p>.05).
overview of HIV/AIDS, including Assessed at the pre-, papers. - The Obstetrical - The intervention
medical aspects and ethics. post-, and 2 months Delivery: faculty Knowledge Scale significantly improved
- Students participated in the follow up. memebers (OKS) (Un- participants‘ willingness to
immersion experience also validated) provide care (p=.036) and
received training in counseling, Attitudes (Validated) knowledge of HIV over
legal dimensions, women and - HIV/AIDS stigma time (p<.001).
infants infected with HIV. Instrument – Nursing
Theoretical framework: Watson‘s Student (HASI-NS)
theory of human caring (19 items)
- The AIDS Attitude
Scale (AAS) (21
items)
Behaviour (Validated)
- The Nurse
Willingness
questionnaire (NWQ)
(13 items) (Dubbert,
et al, 1994)
Ezedinachi E, et I 2 days; Group discussion, Attitudes & beliefs - There was a significant
al., 2002, Nigeria - Intervention group vs. control video-tape (Validated) improvement on
group assessed at baseline presentations - Attitudes toward perceptions of population
- The intervention focused on HIV- and one year follow Delivery: Trainers AIDS (12 items) risk assessment, fear and
related knowledge, HIV up (medical discrimination, and
prevention, discussion of superintendents, sympathy toward treating
stigmatization and discrimination, matrons, chief people with HIV at one-
human rights laboratory year follow up (p<.05).
- The intervention was developed technologists)
using a training of trainers (TOT)
model

324
Geibel S. et al., I , SB Cards, role plays, 2-day HIV training Attitudes (Invalidated) - Both the fear-based and
2017, Bangladesh - The content of the intervention discussion and 90-minute - Attitudes toward value-based stigma were
included HIV and sexual and Delivery: Experts session on issues PLHIV and other link significantly reduced after
reproductive health and rights, experienced in related to stigma and up outreach both training interventions
and issues on stigma and gender. implementing gender, 1-day populations (27 (p<.001).
- The intervention was developed stigma-focused supplemental training items)
using a training of trainers (TOT) trainings. on stigma.
model Assessed at baseline,
6 month and 12 Assessed at baseline,
month follow up midterm training, and
5-6 months after the
second training.
Gross E J., et al., I One day workshop; Lecture Knowledge (Validated) - The intervention
1993, U.S. - The intervention focused on Assessed at pre-, Delivery: nurse with - Knowledge (25 significantly improved
providing information on medical post-, and three experience in items) participants‘ knowledge and
aspects of HIV, psychosocial months follow up. pediatric nursing Attitudes (Validated) attitudes about HIV in
issues,legal issues, universal education - Attitudes (20 items) children post-intervention
precautions, community (p<.001). The knowledge
resources. score had fallen not to pre-
test level at three-month
follow up, while the
attitudes scores maintained
at three-month follow up.
Gutierrez J.M.M., I 90 minutes; Didactic lectures Knowledge (Validated) - The intervention
2014, Saudi Arabia - The intervention focused on Delivery: The - Nurses‘ HIV/AIDS significantly improved
HIV/AIDS related knowledge, assessed at pre- and researcher knowledge (40 items) nurses‘ theoretical
universal precaution and post-intervention Attitudes (Validated) knowledge about
prevention, ethical issues, patient - Nurses‘ Attitudes HIV/AIDS (p<.001);
rights, and stigma reduction towards Patients with - There was no statistically
strategies. HIV/AIDS (9 items) significant change in
Behaviour (Validated) nurses‘ attitudes and
- Acts of comfortableness dealing
discrimination by with HIV/AIDS patients.
nurses (5 items)

325
Held SL, et al., I, C One 4-hour Didactic lecture, Knowledge (Validated) - The intervention
1992, U.S. - Intervention group vs. control educational unit discussion - Knowledge about significantly improved
group Delivery: NS AIDS (34 items) participants‘ HIV/AIDS-
- The content of the intervention Assessed at the Attitudes (Validated) related knowledge,
included HIV related knowledge baseline, one week - Attitudes towards attitudes, and willingness to
and management of HIV after the caring for patients treat the patients (all
infection,, universal precautions, intervention. with AIDS (30 items) p<.001).
addressed feelings associated with Behaviour (Validated)
being a patient with AIDS. - Willingness to treat
the patients (5 items)
Kamiru HN, et al., I Five days didactic PowerPoint Knowledge (Validated) - The intervention
2009, Swaziland - Medical aspects of HIV/AIDS, in-house training. presentations - Knowledge of significantly increased the
such as epidemiology, Assessed at pre- and Delivery: clinicians, HIV/AIDS (11 items) participants‘ knowledge,
pathophysiology, clinical post- intervention. pediatricians, social Attitudes (Validated) attitudes and self-efficacy to
manifestation, diagnosis, workers, program - Self-efficacy (10 provide care toward PLHIV
prevention of mother to child coordinators. items) (all p<.05).
transmission, primary care of - Attitudes toward
HIV-infected child, values AIDS (12 items)
clarification, ART adherence, (Trochim 2004)
nutrition, train the trainer model. (subscale: affect,
belief, and
behaviour)
Kaponda CPN, et I, SB Ten sessions Guided discussions, Knowledge (Validated) - The intervention
al, 2009, Malawi - Focus on knowledge related to intervention role-plays, return - HIV-related significantly improved the
HIV/AID, universal precautions, 90-120 demonstration with knowledge (7 items) hospital workers‘
help individual and families minutes/session; corrective feedback, Attitudes (Invalidated) knowledge about
addressing HIV prevention, and assignment to - Attitudes about HIV/AIDS (p<.001),
ethical issues for health workers assessed at baseline practice a special HIV/AIDS (25 items) improved attitudes toward
related to HIV. and after the skills PLWHA (p<.001) and
Theoretical framework: The world intervention. Delivery: Trained higher self-efficacy for HIV
health organization primary health- peer-group prevention (p<.001).
care model, social cognitive learning facilitators
model

326
Kemppamen J.K., I, SB, C Three 1-hour Group discussion, Knowledge (Invalidated) - None of the intervention
et al., 1996, U.S. - Three arms: group discussion sessions; simulation games, - Infectious disease had a significant impact on
group vs. patient contact group open-ended knowledge (single the nurses‘ attitudes either
vs. knowledge control group assessed at baseline, questionnaire, video item) at post-intervention or
- Group discussion group focused after the programme in which Attitudes (validated) during 6 months follow up.
attitudes and beliefs about AIDS intervention, and 3 AIDS patients - The prejudicial
patients; Patient contact group moths, 6 month described their evaluation scale (12
focused on observing and follow up. feelings, clinical items) (Kelly et al.,
practicing infection control practice, and caring 1988);
techniques while caring for for patients with - The Social inventory
patients with AIDS; Knowledge AIDS scale (7 items) (Kelly
control group only provided Delivery: Master‘s- et al., 1988);
training on universal precautions. level nurse who had Affective component
experience in care of - AIDS patient care
acutely ill patients comfort and
including PLWHA. confidence (two
items) (invalidated)
Behaviour (Invalidated)
- Nursing willingness
questionnaire (4
items) (Kemppainen
et al, 1992, Dubbert
et al, 1994);

327
Lewis DA, et al., I One-day workshop; Didactic Knowledge (Invalidated) Post interviention:
1996, UK - The intervention focused on oral presentation, case - HIV/AIDS-related - 38% of participants felt
manifestation of HIV/AIDS and assessed at baseline, studies, role-play Knowledge (4 items) their attitude had changed
infection control, case studies, after the Delivery: Attitudes (Invalidated) towards treating people
local resources and referral intervention, and 12- Presentation was - Attitudes towards with HIV;
services month follow up. given by a dentist HIV patients - 59% were most likely to
involved in providing provide care;
a service for PLHIV - 72% would change working
practice.
One year follow up:
- Eight of ten (80%)
participants had changed
their working practice.
Li L, et al., 2013, I, SB Four group sessions, Interactive Attitudes (Validated) - Compared to control group,
China - Intervention group vs. control and 3 reunion techniques, such as - HIV/AIDS-related the intervention
group sessions (1.5 facilitators stigma and significantly reduced
- The intervention focused on hours/session); demonstration, group discrimination (8 prejudicial attitudes at 6
universal precautions, stigma, discussion, pair items) months (p< .001) and 12
care for patients and building up a assessed at baseline, sharing and role-play, Behaviour (Validated) month follow-up (p< .001)
better medical environment. 6- and12-month discussion, games - Avoidance intent (8 - The intervention
- Theoretical framework: follow up. Delivery: Trained items) significantly reduced
Diffusion of innovation theory. popular opinion avoidance intent (p< .001)
- The study used the Popular leaders at 6 months.
opinion leaders (POLs) model - The intervention effects on
avoidance intent was
sustained and strengthened
at 12 months.

328
Lohiniva A.L., et I, SB, C Five interactive Didactic lectures, Attitudes (Validated) - The overall value-based and
al., 2015, Egypt - Intervention group vs. control training modules; sharing sessions with - Attitudes toward fear-based stigma scores
group 5 hours/module; PLHIV, risk AIDS (21 items) were significantly lower in
- The intervention focused on HIV- assessment exercises, the intervention group
related knowledge, stigma, assessed at baseline case studies, compared to the control
medical ethics, childbirth, and after the discussions group (p<.001).
infection prevention, standard intervention. Delivery: Taskforce – - Significant reduction in
precautions, techniques for National AIDS overall stigma scores were
invasive procedures, and Program (NAP) observed in the intervention
interaction with PLHIV. officials, global group compared to the
disease detection and control group (48% vs.
response program 14%).
project staff, PLHIV,
directors of various
surgical departments,
head of quality
assurance team, head
of the inflectional
control unit, and
director of the
intervention hospital
Lueveswanij S., et I, SB, C Three day training Didactic lectures, Knowledge (Invalidated) - The intervention
al., 2000, Thailand - Intervention group vs. control program; role-play, sharing - Knowledge of significantly increased
group sessions with PLHIV, HIV/AIDS (4 items); participants‘ knowledge
- The intervention focused on HIV- assessed at baseline videotape for Attitudes (Invalidated) (p<.001), attitudes (p<.05),
related knowledge, oral and three months infection control - Attitudes, beliefs and and infection control
manifestations, infection control, after the Delivery: Lectures behaviours related to practice (p<.001).
role of oral health personnel in intervention. from Faculty of HIV/AIDS (4 items);
providing treatment, counseling medical and Faculty Behaviour (Invalidated)
and referral for HIV/AIDS of dentistry - Infection control
patients, and interaction with practice (5 items).
PLHIV.

329
Mahendra V.S., et I, SB, CS, C, B, S 14 hours (Two-hour Didactic lectures, Knowledge (Invalidated) - The intervention
al., 2006, India - The intervention included session, organized sharing sessions with - Knowledge of significantly improved
development of hospital every alternate day PLWHA, site visits, HIV/AIDS (10 items) health care workers‘
guidelines for HIV/AIDS care and over two weeks). feedback Attitudes (Invalidated) knowledge and attitudes
management, sensitization of Delivery: - The stigma index toward people living with
health care workers through Assessed at baseline representatives of 1) Attitude toward HIV/AIDS (p<.05).
training, expansion and and six to eight AIDS service (e.g. PLHA (12 items) - The intervention
strengthening HIV testing and months after the lawyer, human rights 2) Attitude toward significantly improved
counseling services, educational intervention activist) health care doctors‘ HIV testing and
and development of material on organizations and related practice counseling attitudes and
infection control. PLHIV . (9 items) practices (p<.05).
- Staff training focused on HIV
related knowledge, testing and
counseling, confidentiality and
legal issues, stigma and
discrimination, continuum of care,
site visits to care home.

330
Mak WWS, et al., I, C K+EXG: 30-miute Didactic lectures, Knowledge (Validated) - Pre-program to post-
2015, Hong Kong - Knowledge + experiential games didactic session + sharing sessions with - HIV/AIDS-related program improvements
(K+EXG) group vs Knowledge + two experiential PLHIV Knowledge (23 achieved large effect sizes
in vivo contact (K+IVC) group games; Delivery: Research items) (Lau et al., on all six variables in both
- K+EXG group focused on K+IVC: 30-miute assistant, PLHIV 2007); groups.
HIV/AIDS-related knowledge, didactic session + Attitudes (Validated) - The changes were similar
and two different experiential 90-minute sharing - Stigmatizing attitudes between the K+EXG group
games; sessions. toward PLHIV (14 and the K+IVC group
- K+IVC group focused on items) (Andrewin et (F(6,81)=.58, p>.05).
HIV/AIDS-related knowledge, Assessed at baseline, al., 2008); - Across both groups,
and sharing sessions hosted by after the - Discrimination (7 improvements in
two PLHIV intervention, and one items) (Abell et al., HIV/AIDS-related
month post-program. 2007); knowledge and support for
- Support for coercive coercive policies were
policies (6 items) maintained from post-
(Herek et al., 1993); program to one month
Affective component follow up.
- Fear of infection (5
items) (Carter, et al.,
1996)
Behaviour
- Willingness to treat
(10 items) (Andrewin
et al., 2008)

331
McCann TV, et al., I, C 6-week unit of Didactic lectures, Knowledge (Validated) - The intervention
1998, Australia - The intervention focused on study; group discussions, - Knowledge about significantly improved
HIV/AIDS-related knowledge, multimedia HIV/AIDS (18 participants‘ knowledge
infection control issues, care and assessed before and presentations, and items); (p<.05), attitudes (p< .005),
treatment of patients with after the seminars with Attitudes (Validated) willingness to work with
HIV/AIDS, attitudes, and intervention. PLWHA, nurses, Affective component colleagues and patient with
contacted with people with social workers and - Fear of contagion (8 HIV/AIDS (p<.05)
HIV/AIDS community AIDS items) - Fear of contagion was
organization workers. - Attitudes towards evident. There was stronger
Delivery: NS PLWHA (4 items); agreement that they would
Behaviour take additional precautions
- Willingness to work on finding out that one of
with PLWHA (4 their patients was HIV-
items). positive.
Mockiene V, et al., I, C 2-day (13 hours); Didactic lectures, Knowledge (Validated) - There was significant
2011, Lithuania - Three arms group discussions, - Knowledge about improvement in HIV
- Experimental group 1 (EG1): the assessed at baseline sharing sessions with HIV (33 items); knowledge in EG1 group
intervention included workshop and 3 months after PLHIV, film about Attitudes (Validated) (p<.001, paired t-test). EG1
and written materials, the content the intervention. HIV, lecture - Attitudes toward group participants‘ attitudes
focused on HIV-related handouts, HIV-infected patients had improved positively,
knowledge, counseling, and distribution of and HIV/AIDS scale but not statistically
ethical considerations; written materials (35 items) (Suominen significant;
Experimental group 2 (EG2): Delivery: Research et al., 2008) - There was no significant
intervention included written team collaborated improvement in HIV
materials, the content focused on with the Lithuanian knowledge and attitudes in
HIV-related knowledge, AIDS centre. the EG2 group and control
counseling, and ethical group.
considerations;
Control group: no intervention.

332
Nanayakkara G et I, SB, C 2h/session, Lectures, small group Knowledge (Validated) - The knowledge and
al., 2017, SriLanka Intervention group vs control group Six sessions. discussion, group - HIV/AIDS attitudes toward HIV of the
- The intervention focused on HIV Assessed at pre- and activities, case knowledge scale (not intervention group
epidemiology, diagnosis and post- intervention. scenarios, testimony specified) improved significantly after
treatment, transission, standard of PLHIV Attitudes (Validated) the intervention when
precautions, management of HIV Delivery: HIV care - Generic AIDS compared to the control
patients in the hospitals and specialist, PLHIV attitudes scale group (all p< 0.01).
communities, HIV related stigma, (GAAS) (21 items)
and testimonials of PLHIV. (Fronman et al.,
1992)

Operario D, et al., I, SB, C One week group Didactic lectures, Knowledge (Validated) - The educational program
2016, China - Intervention group vs. control training, 2 months clinical practice, case - HIV/STI knowledge significantly improved
group clinical practice, two studies, small group (198 items) physicians‘ knowledge,
- The intervention focused on additional 2-day discussions, treatment, and risk
HIV/AIDS-related knowledge and group ―booster‖ problem-solving reduction counseling
treatment, behavioural risk training sessions; exercises, role-plays, (p<.05).
reduction counseling, stigma sharing sessions with
reduction, preventions given by assessed at baseline, PLWHA
people with HIV/AIDS 3 months,6 months Delivery: NS
Theoretical framework: Social and 9 months after
learning theory the intervention.

333
Orlander Jay, et al., I, C Weekly, Weekly review of Knowledge (Validated) - The intervention improved
1994, U.S. Intervention group vs. control group Six months, previous weeks‘ - HIV-related residents‘ attitudes toward
- The intervention was training in a Assessed at pre-, cases, brief didactic knowledge Attitudes PLHIV (p=.08)
diagnostic evaluation unit (DEU) post- and three discussion (Validated) - Knowledge scores increased
of a HIV staging and triage clinic months follow up. Delivery: NS - HIV-related attitudes for both groups, and there
(Cook, et al., 1990) was no statistically
Self-efficacy significant difference
- Confidence to care between the two groups.
for patients (single - There was no statistically
item) significant difference
Behaviour (Unvalidated) between the groups in their
- Willingness to treat willingness to treat (p>.05),
(single item) but there was significant
improvement in the
confidence to care patients
in the intervention group
(p<.001) at 3 moths follow
up.

334
Pisal Hemlate, et I, SB, CS, C 4-day; Lectures by PLHIV, Knowledge (Invalidated) - The education intervention
al., 2007, India - The intervention focused on preparation to deliver - HIV knowledge (71 significantly improved
knowledge of HIV/AIDS, care assessed at the future training items) nurses‘ HIV/AIDS
and treatment, HIV/AIDS stigma, baseline and after workshop Attitudes (Invalidated) knowledge (p< .001),
discrimination, confidentiality, the intervention. Delivery: Trained - Attitudinal questions reduced their fear of
counseling, and ethical nurses, social (17 items) interaction with people
considerations. scientist with Affective component living with HIV/AIDS
- The educations program was expertise in - Fear associated with (p< .001);
developed using a training of HIV/AIDS, PLHIV, managing HIV/AIDS - The education intervention
trainers (TOT) model peer educators with a patients (6 items) significantly improved
local sex workers‘ nurses‘ attitudes associated
organization with consent and
confidentiality, and stigma
and discrimination
(p<.001). However, there
was no change in nurses‘
attitudes related to cleaning
stool or urine of HIV/AIDS
patients.

335
Pulerwitz J, et al., I, SB, CS, C,B, S Group 1: 1.5 days Didactic lecture, Attitudes (Validated) - Both Group 1 and Group 2
2015, Vietnam - Two arms intervention training; Group 2: 2 sharing sessions with Affective component interventions were
- The intervention included six days training; PLWHA - Fear-based stigma (4 successful in reducing all
components: establishment of a Delivery: Trainers items) three types of stigma
hospital steering committee, staff assessed at the with expertise in - Social stigma (5 (p<.001)
training, hospital policy baseline and after HIV, universal items) - The Group 2 intervention
development, provision of the intervention. precautions, or Behaviour (Invalidated) had a greater impact on
material supplies, provision of stigma and - Enacted stigma (3 stigma than Group 1
educational materials, and discrimination, and items) (p<.05).
monthly monitoring. familiarity with
- Group 1: HIV knowledge, participatory
focused on knowledge of HIV, methods, trainers
infection control measures, from local AIDS
Group 2: half-day training of HIV center, PLHIV
knowledge + extra half day
training on social stigma, focused
on knowledge of HIV, infection
control measures, and social
stigma, legal rights of HIV
positive patients.
Conceptual frame work for HIV
stigma.

336
Shah SM, et al., I, C Two 1-hour sessions Powerpoint Knowledge (Validated) - The intervention
2014, India - Intervention group vs. control (these sessions were presentation, - HIV-related significantly improved HIV-
group administrated 1 question and answer knowledge and related knowledge (p=.001),
- The intervention focused on HIV- week apart); session, sharing transmission reduced HIV transmission
related knowledge, HIV sessions with PLHIV misconceptions (14 misconceptions (p=.04),
prevention, health care associated assessed at the Delivery: PLHIV items) blame (p=.04) and reduced
stigma, instrumental and symbolic baseline and 1 week Attitudes (Validated) discrimination intent when
stigma, preventions given by a after the Affective component dispensing medications
PLHIV. intervention. - Worry about HIV (p=.01).
infection (2 items) - Compared to control group,
- Blame (single item) there was no difference in
Behaviour (Validated) worry expressed about
- Intent to discriminate becoming HIV infected
against PLHIV (p=.09), and number of
- coercive policies endorsed
(p=.08).
Stewart KE, et al., I, SB, CS 90 minutes Didactic lectures, Knowledge (Validated) - The education-only and
1999, UK - Didactic group vs. Social role-play exercises, - Knowledge of SCT-based workshops were
cognitive theory (SCT)-based Assess at the question and answer HIV/AIDS (28 effective in increasing HIV-
group. baseline, after the session items); related knowledge, positive
- Didactic group focused on intervention, and 8 Delivery: The Attitudes (Validated) attitudes, comfort and intent
lectures about HIV/AIDS weeks follow-up researcher - Attitudes towards at post-test.
information without evaluation. Setting: University HIV and PLHIV (10 - The SCT-based workshop
demonstration of techniques; medical center and items); yielded more positive
- SCT-based group focused on brief hospitals Behaviour (Validated) results for all four outcome
lectures (30 minutes) and - Comfort with and variables at 8-week follow
modeling and role-playing intent to utilize up (F2,71 =4.27, p<.02)
exercises (60 minutes), and preventive
demonstrations of risk assessment behaviours
and HIV counseling.
Theoretical framework: Social
cognitive theory (SCT)

337
Stiernborg, M, et I, C 3-hours session; Didactic lectures, Knowledge (Validated) - The experimental group had
al., , 1996, - Three arms intervention: didactic role-play exercises, - HIV/AIDS related significantly higher mean
Philippines teaching group vs. experiential assessed at the question and answer knowledge (28 knowledge scores (p<.05)
learning group vs. control group baseline and after session, case studies, items); and attitudes scores than
- Didactic teaching group focused the intervention. sharing sessions with Attitudes (Validated) both the didactic and
on information about HIV/AIDS, PLWHA - Attitudes to caring control groups (p<.05);
participation by a PLWHA; Delivery: Teachers, for HIV/AIDS - The didactic group had
Experiential learning group doctor and nurse patients (18 items) significantly higher mean
focused on training with an knowledge scores than the
experiential participation by a control group (p<.05), and
PLWHA. the didactic teaching group
significantly reduced the
fear of attracting HIV
(p<.05).

Uwakwe C.B.U, et I 7-week training Lecture, seminar, Knowledge (Validated) - Compared to control group,
al., 2000, Nigeria - Intervention group vs. control sessions; multimedia - HIV/AIDS the intervention
group presentation, knowledge significantly improved
- The intervention focused on assessed at the discussion sessions, Attitudes (Validated) nurses‘ HIV/AIDS related
prevention measures in their baseline and after small media - Attitudes towards knowledge, attitudes and
personal and professional lives, the intervention. communication (e.g. HIV/AIDS disease disposition to comply with
sensitization problem-based print and electronic and diagnosed universal precautions (all
participatory approach to learning media, audio-visual patients p<.05).
was adopted. materials) Behaviour (Validated)
Delivery: NS - Prevention
behaviours in
professional practice

338
Uys L, et al., 2009, I, C 3-day workshop; Didactic Attitudes (Validated) - Nurses in the intervention
Lesotho, Malawi, - The intervention focused on presentation, contact - HIV/AIDS stigma teams demonstrated no
South Africa, HIV/AIDS stigma, outcomes of assessed at baseline with PLWHA, Instrument-Nurses change in stigma but a
Swaziland, stigma, coping with stigma, and after the participatory (HISI-N) (19 items) significantly higher
Tanzania identifying stigma interventions intervention. activities - Generalized Self- percentage of the nurses
and local examples Delivery: Nurses Efficacy Scale (11 were tested for HIV by the
who were interested items) end of the project (p≤.001),
in or involved with - Self-Esteem Scale there was no significant
HIV/AIDS care, (10 items) difference in self-esteem
PLHIV (p=.08) and self-efficacy
(p=.21)
Valois P, et al., I 3-session Presentation, short Knowledge (Validated) The intervention significantly
2001, Canada - Intervention group vs. control 30-minute/session discussion, question - Knowledge of improved
group One session/month and answer session, HIV/AIDS (15 - HIV/AIDS related
- The persuasive message case studies items); knowledge (p<.001);
intervention focused on increasing assessed at the Delivery: NS Attitudes (Validated) - Intention of providing care
nurse‘s role in providing care for baseline and after - Global attitudes (6 to people living with
people living with HIV/AIDS, the intervention. items); HIV/AIDS (p<.01);
universal precautions. - Global social norm (2 - Belief-based attitude
Theoretical framework: Theory of items) (p<.01);
planned behaviour Behaviour (Validated)
- Intention of
providing care to
people living with
HIV/AIDS (2 items).

339
Varas-Diaz N, et I, SB 9-hours workshop Didactic lecture, case Knowledge (Validated) The intervention improved
al., 2013, Puerto - Intervention group vs. control divided into three studies, small group - HIV knowledge (10 knowledge, self-efficacy, and
Rico group sessions (3- discussions, media items); positive emotions. significantly
- The intervention focused on hour/session); outlets Attitudes (Validated) reduced HIV stigma (p=.0001),
information on HIV stigma, its Delivery: NS - HIV stigma- The and difference in HIV stigma
consequences on service delivery, assessed at the Spanish HIV Stigma levels between the two groups
the role of negative emotions in baseline, Scale (SHASS) (44 sustained for 6 months (p=.03)
HIV stigma and skills for stigma- immediately after items) and 12 months follow up
free interactions with PLHIV. the intervention, 6 - Self-efficacy for (p=.004).
Theoretical framework: Social months and 12 providing services (9
cognitive theory months follow up. items)
Wang Debin, et al., I, SB, CS 10 days workshop + Lecture Knowledge (Invalidated) - The intervention
2009, China - The intervention focused on HIV one month practice + Delivery: researchers - HIV/AIDS related significantly increased
epidemiology, treatment, one week booster with expertise in knowledge health care providers‘
syndrome management, group training + one HIV/STI prevention Attitudes (Invalidated) knowledge, attitudes, and
behaviours risk reduction month practice again and treatment - HIV-related stigma risk reduction counseling
counseling and stigma reduction. + one week group and discrimination skills toward HIV/AIDS (all
workshop Skills p< 0.01).
Model: Workshop-practice model - Risk reduction
Assessed at baseline counseling
and six-months
follow up

340
Williams A.B, et I 5-day workshop Didactic lecture, Knowledge (Invalidated) - The intervention
al., 2006, China - The intervention focused on comprising didactic question and answer - HIV/AIDS significantly improved
HIV/AIDS related knowledge, lectures; session, (small) knowledge (24 participants HIV/AID
human sexuality, addictive disease group discussions, items); knowledge (p<.001),
and bereavement, prepared and assessed at the video of PLWHA, Attitudes (Validated) attitude toward patient with
delivered sample lessons as baseline and after powerpoint slides, - The AIDS attitude HIV/AID (p<.001), and
workshop activities. the intervention. transparencies, scale-G (AAS-G) (21 willingness to providing
- The intervention was developed learning activities items) (Froman et al., nursing care to these
using a training of trainers (TOT) Delivery: expert, 2001); patients (p< .001).
model. AIDS-experienced Behaviour (Validated)
Theoretical framework: Bloom‘s Chinese nurse, - The Nursing
Taxonomy counselor, staff of Willingness
drug treatment center Questionnaire (13
items)
Wu S, et al., 2008, I, SB , C One 4-hour session, Games, small group Knowledge (Validated) - Compared to control group,
China - intervention group vs. control discussion, role-play - Knowledge about the brief intervention
group assess at the session, sharing universal significantly improved
- Intervention focused on HIV baseline, 3- and 6- sessions with precautions; participants‘ protection of
related information and policies, moths follow up PLWHA Attitudes (Invalidated) patients‘ confidentiality,
universal precautions, equal Delivery: Physician - Attitudes toward rights to HIV testing,
medical treatment to everyone, specializing in AIDS PLWHA practice of universal
testimony by two HIV advocates, care, HIV advocates Behaviour (Unvalided) precautions, and reduced
role-play sessions of - Practice of universal negative feelings toward
discrimination in society. precautions (single people living with
item) HIV/AIDS at 3 months and
6 months (all p<.05).

341
Wu Z.Y, et al., I, CS Dosage of the Didactic lecture, case Knowledge (Invalidated) - Compared with control
2002, China - Intervention group vs. control workshop: NS. studies, role-play, - Knowledge of group, the knowledge,
group video presentations universal attitudes, and condom use
- The content of the intervention Evaluation of the discussion, precautions; were significantly higher in
included HIV related knowledge workshops were preparation to deliver Attitudes (Invalidated) the intervention group at 7
and prevention, role-playing in conducted at the future training - Attitudes months and 12 months
counseling, work plans for baseline, 7- and 12- workshop, follow up (all p<.01).
secondary and tertiary workshops, moths follow ups. disseminating AIDS
development of educational educational message
materials, work plans for through filers,
universal precautions. posters, bill-boards,
- The intervention was developed blackboards, radios,
using a training of trainers (TOT) TVs and
model loudspeakers
Delivery: Trained
health workers
Yiu J.W., et al., I, C Knowledge only Didactic lecture, Knowledge (Validated) - In both groups, significant
2010, Hong Kong - Knowledge only group vs. group: 50-minutes question and answer - AIDS knowledge (20 improvement in AIDS
Knowledge + contact group. lecture session, sharing items); knowledge, stigmatizing
- Knowledge only group consisted sessions with Attitudes (Validated) attitudes, fear of contagion,
of standard lecture, focused on Knowledge contact PLWHA - Stigmatizing attitudes willingness to treat, and
HIV/AIDS related knowledge; group: 50-minutes Delivery: Retired (15 items); negative affect were found
- Knowledge and contact group lecture + 50-minutes nurse, PLHIV, AIDS Affective component at post test and sustained at
focused on HIV/AIDS related contacted with HIV care workers - Fear of contagion (4 follow-up (all p<.001).
knowledge, and contact with patients items); - Inter- group comparisons at
PLWHA. - Emotional well-being post test showed that the
assessed at the (20 items). effectiveness of knowledge-
baseline, after the Behaviour (Validated) contact program was
intervention, and 6 - Willingness to treat significantly greater than
weeks follow up. (3 items) knowledge program in
improving stigmatizing
attitudes.

342
Young E, et al., I One-day workshop; Introduction film, Knowledge (Invalidated) - The intervention
1989, U.S. - The intervention focused on HIV- Assessed at pre-, lecture. - HIV-related significantly improved
related information, such as risk post- and three Delivery: NS knowledge (10 items) nurses knowledge of HIV,
behaviours, homosexuality. months follow up. Attitudes (Validated) attitudes (p<.001), fearful
- Attitudes toward of caring PLHIV (p=.005),
AIDS and and willingness to care
homosexuality (17 PLHIV from pre-test to
items) (Gabay, 1985) post-test and from pre-test
Affective component to 3-month follow up (all
(invalidated) p<.001)
- Fear for caring
PLHIV (single item)
Behaviour (invalidated)
- Willing to care
PLHIV (single item)
a
Study design abbreviation: QE/NC: Quasi-experimental with no control group; QE/C: Quasi-experimental with control group; RCT: Randomized controlled trial
b
Interventions type abbreviation: I: Information based; SB: Skills building; CS: Counseling/support; C: Contact with affected groups; B: Biomedical strategies; S: Structural strategies.
HIV: human immunodeficiency virus; AIDS: Acquired Immune Deficiency Syndrome; PLWHA: People living with HIV/AIDS; STIs: sexually transmitted infections; PLHIV: People living with HIV; NS: Not specified

343
Table 6-4 Effect size of HIV/AIDS related-knowledge
Study Treatment group Control group Effect size
Sample size (n) Pre Post Longest follow Sample Pre Post Longest Pre-post Longest
(mean SD) (mean up time point size (n) (mean (mean follow up effect size follow up
SD) (mean SD) SD) SD) time (Conhen’s time point
point d) effect size
(mean (Conhen’s
SD) d)
All A.C., et al., 39 44.92 (10.29) 39.08 NA -
1997, U.S. (11.21)
38.00 (8.64) 36.03
(7.39)
Arora S., et al., 33 15.09 (5.4) 30.39 (7.6) 32 17.5 22.94 d=0.86
2014, India (12.1) (9.5)
Balogun J, et al., 26 24.4 (4.2) 25.5 27.9 (2.2) 23 23.9 27.0 (3.3) 27.2 (3.0) d=0.47
1998, U.S. (3.8) (4.3)
Bluespruce J., et al., 47 - - NA
2001, U.S.
Britton P, et al., 22 10.95 (2.90) 16.41 NA
1999, U.S. (2.28)
Buskin, SE, et al., 122 - - NA
2002, China
Carney JS, et al., 22 17.77 21.83 20 17.26 17.94
1999, U.S.

Charuluxananan S. 177 7.95 (0.98) 9.5 - NA

et al., 2000, (0.78)
Thailand
Chisholm M, et al., - NA
1999, U.S.
Collins P.Y., et al., 42 3.11(0.75) 3.87 NA d=1.17
2006, South Africa (0.54)
73 (19) 86 (13) d=.74

344
Diesel H, et al., 8 73.44 (11.3) 77.60 81.25 (3.1) 18 76.63 80.32 80.09 d=0.06 d=0.52
2013, U.S. (8.6) (6.4) (5.1) (6.5)
Ezedinachi E, et al., -
2002, Nigeria
Geibel S. et al., - NA
2017, Bangladesh
Gross E J., et al., 205 78.9 (9.6) 91.0 88.3 (7.3) NA
1993, U.S. (7.4) (N=112)
Gutierrez J.M.M., 58 23.7 30.6 NA
2014, Saudi Arabia
Held SL, et al., 47 21.38 (3.88) 28.89 52 20.85 21.00 d=1.83
1992, U.S. (2.46) (4.08) (4.39)
Kamiru HN, et al., 97 68.7 (13.7) 84.0 NA
2009, Swaziland (12.0)
Kaponda CPN, et 366 80.7 92.1 NA
al, 2009, Malawi (n=561)
Kemppamen J.K., -
et al., 1996, U.S.
Lewis DA, et al., 29 - - NA
1996, UK
Li L, et al., 2013, - - 880
China
Lohiniva A.L., et -
al., 2015, Egypt
Lueveswanij S., et 97 - 42 -
al., 2000, Thailand

Mak WWS, et al., 46 65.41 (11.56) 78.36 77.91 (8.51) 42 63.77 74.74 76.23 η2 =.590 η2 =.431
2015, Hong Kong (8.33) (11.14) (9.52) (14.98) (game-based (game-based
group) group)
η2 =.616
(contact η2 =.319
group) (contact
group)

345
Mahendra V.S., et 884 - - NA
al., 2006, India
McCann TV, et al., 74 - - NA
1998, Australia
Mockiene V, et al., 69 EG1: 19.4 (3.674) 25.3 (4.189) 59 18.7 17.9 d=1.89
2011, Lithuania (3.428) (3.635)

70 EG2: 20.7 (3.701) 21.9 (3.651) d=1.10

(n=63)
Nanayakkara G et 65 18.03 (3.84) 26.97 64 16.84 15.78 d=2.89
al., 2017, SriLanka (3.68) (4.08) (4.05)
Operario D, et al., 121 (Biology) 35.0 (0.12) 128 23.2 38.2 d=26.67
2016, China 23.4 (0.09) (0.09) (0.12)

(Symptom) 32.0 (0.18) 24.1 38.6 d=38.8

23.7 (0.13) (0.14) (0.16)
(Management) 26.4 (0.17) 16.0 25.8 d=3.75
15.6 (0.11) (0.09) (0.15)
(Treatment) 13.8 (0.15) 8.70 13.1 d=4.22
8.40 (0.11) (0.10) (0.18)
(Counselling) 27.6 (0.17) 14.7 32.6 d=36.76
15.5 (0.15) (0.14) (0.09)
Orlander Jay, et al., 21 - - - 20 - - -
1994, U.S.
Pisal Hemlate, et 377 - - NA
al., 2007, India
Pulerwitz J, et al., -
2015, Vietnam
Shah SM, et al., 45 78.4 (9.1) 8.7 (8.7) 46 79.7 -1.9 (8.4) d=1.06
2014, India (change) (10.9) (change)
Stewart KE, et al., 44 - - 44 - -
1999, UK
Stiernborg, M, et EG1: 182 5.7 (3.5) 8.5 (3.4) 195 5.9 (3.6) 6.0 (3.6) d=0.70
al., , 1996, (transmission)
Philippines

346
 EG2: 185 6.5 (3.6) 10.0 d=0.95
(2.4)
EG1: 182 3.7 (1.3) 4.6 (1.4) 3.1 (1.1) 3.4 (1.2) d=1.00
(precaution)
EG2: 185 3.7 (1.1) 5.0 (1.1) d=1.83
EG1: 182(Mixed 6.1 (1.7) 7.0 (1.6) 5.6 (1.8) 5.7 (1.7) d=0.74
knowledge)
EG2: 185 6.7 (1.5) 8.1 (1.4) d=0.79
Uwakwe C.B.U, et 68 - - 73 - -
al., 2000, Nigeria
Uys L, et al., 2009, - - -
Lesotho, Malawi,
South Africa,
Swaziland,
Tanzania
Valois P, et al., 27 - - 47 - -
2001, Canada
Varas-Diaz N, et 208 -
al., 2013, Puerto
Rico
Wang Debin, et al., 69 - - NA
2009, China
Williams A.B, et NA
al., 2006, China
Wu S, et al., 2008, 70 - - 68 - -
China
Wu Z.Y, et al., 296 - - 270 - -
2002, China
Yiu J.W., et al., 55 14.02 (2.48) 16.50 15.92 (1.71) 47 12.91 16.69 15.35 d=0.14 d=0.34
2010, Hong Kong (1.28) (2.23) (1.42) (1.67)
Young E, et al., 200 - NA
1989, U.S.

347
Table 6-5 Effect size of attitudes towards caring for PLWHA

Study Treatment group Control group Effect size

Sample Pre Post Longest Sample Pre Post Longest follow Pre-post Longest
size (n) (mean SD) (mean SD) follow up size (n) (mean (mean up time point effect size follow up
time point SD) SD) (mean SD) (Conhen’s time point
(mean SD) d) effect size
(Conhen’s d)
All A.C., et al., 39 44.92 (10.29) 39.08 NA -
1997, U.S. (11.21)
38.00 (8.64) 36.03 (7.39) -
Arora S., et al., 33 103.36 (4.17) 129.12 32 104.1 112.22 (32.9) d=0.67
2014, India (13.5) (7.5)
Balogun J, et al., 26 131.1 (19.7) 129.6 (25.2) 144 (21.1) 23 120.0 128.2 126 (29.1) d=0.11 d=0.29
1998, U.S. (28.0) (27.0)
Bluespruce J., et 47 - - - NA
al., 2001, U.S.
Britton P, et al., 22 (Comfort) 8.50 (1.79) NA
1999, U.S. 6.68 (2.17)
(Skill) 11.27 (2.07)
7.14 (2.30)
Buskin, SE, et al., 122 - - NA
2002, China
Carney JS, et al., 22 64.9 75.45 20 65.67 65.58
1999, U.S.

Charuluxananan S. 177 - - NA
et al., 2000,
Thailand
Chisholm M, et al., 104 79.28 (13.72) 86.59 NA
1999, U.S. (12.74)
Collins P.Y., et al., 42 3.37 (.56) 3.69 (.61) NA d=.54
2006, South Africa
Diesel H, et al., 8 (AIDS -0.54 (0.3) -0.70 (0.2) 18 -0.75 (0.4) -0.80 (0.4) -0.71 (0.3) d=.0.13 d=1.05

348
2013, U.S. attitudes)
-0.44 (0.3)
(stigma) 27.38 (9.2) 28.50 (7.4) 21.89 23.67 24.50 (9.0) d=0.02 d=0.01
25.50 (6.0) (5.3) (7.3)
Ezedinachi E, et 1072 - - 480 - -
al., 2002, Nigeria
Geibel S. et al., 300 - - NA
2017, Bangladesh
Gross E J., et al., 205 73.6 (8.2) 78.1 (7.3) 77.5 (7.4) NA
1993, U.S. (N=112)
Gutierrez J.M.M., 58 2.75 (0.57) 2.56 (1.03) NA
2014, Saudi Arabia
Held SL, et al., 47 116.68 (18.89) 123.32 52 121.21 117.96 d=0.30
1992, U.S. (16.69) (20.18) (19.22)
Kamiru HN, et al., 50 55.3 (7.3) 57.5 (7.4) NA
2009, Swaziland
72 Self efficacy 42.5 (4.9)
35.8 (8.7)
Kaponda CPN, et 366 1.46 (0.84) 1.09 (0.42) NA
al, 2009, Malawi (blame) (n=561)
366 2.96 (0.23) 2.97 (0.18)
(contact) (n=561)
366 (self- 2.78 (0.41) 2.90 (0.29)
efficacy)
Kemppamen J.K., 18 - - 18 - -
et al., 1996, U.S.
Lewis DA, et al., 29 - - NA
1996, UK
Li L, et al., 2013, 880 - - - 880 - - -
China
Lohiniva A.L., et 203 4.0 (Value- 2.1 144 4.4 3.8
al., 2015, Egypt based stigma)
3.6 (fear- 1.1 3.9 3.2
based stigma)
Lueveswanij S., et 97 - - 42 - -

349
al., 2000, Thailand
Mak WWS, et al., 46 33.87 (8.09) 30.11 (7.13) 31.02 (7.18) 42 33.79 29.07 31.05 (9.55) η2 =.379 Pre-test to
2015, Hong Kong (stigmatized) (contact (9.34) (8.79) (game-based follow up
group) group) η2 =.219
(game-based
η2 =.405 group)
(contact η2 =.140
group) (contact
group)

14.61 (4.00) 12.83 (3.07) 13.46 (3.67) 15.12 12.52 13.29 (4.36) η2 =.230 η2 =.346
(discriminatio (4.91) (3.97) (game-based (game-based
n) group) group)
η2 =.083 η2 =.184
(contact (contact
group) group)
15.33 (4.09) 13.24 (3.69) 13.57 (4.17) 15.12 12.52 13.29 (4.36) η2 =.280 η2 =.457
(fear) (4.91) (4.09) (game-based (game-based
group) group)
η2 =.211 η2 =.264
(contact (contact
group) group)
Mahendra V.S., et 884 42.79 38.07 NA
al., 2006, India
McCann TV, et al., 74 - - NA
1998, Australia
Mockiene V, et al., 69 2.80 (.701) 2.95 (.613) 59 2.81 2.74 (.585) d=0.35
2011, Lithuania (.695)
70 3.00 (.758)
Nanayakkara G et 65 64.88 (11.13) 73.82 (9.66) 64 64.25 61.41 d=1.18
al., 2017, SriLanka (10.05) (11.33)
Operario D, et al., - 128
2016, China
Orlander Jay, et al., 21 - - - 20 - - -
1994, U.S.

350
Pisal Hemlate, et 371 67.27 (11.998) 21.423 NA
al., 2007, India (consent (13.330)
and
confidentia
lity)
371 42.135 16.39
(stigma) (22.970) (15.228)
Pulerwitz J, et al., 493 5.9 (2.1) (fear) 5.1 (1.5) 302 5.8 (1.9) 4.6 (1.0) d=20.00
2015, Vietnam (n=482) (n=315)
8.6 (3.4) 7.4 (2.8) 7.9 (2.8) 6.6 (2.3) d=0.16
(Social
stigma)
Shah SM, et al., 45 -
2014, India

Stewart KE, et al., 44 - - 44 - -

1999, UK
Stiernborg, M, et EG1: 182 18.8 (3.4) 18.3 (3.2) 195 19.0 (3.3) 18.6 (3.4) d=0.03
al., , 1996, (general
Philippines attitudes)
EG2: 185 18.8 (3.7) 20.0 (3.8) d=.459
EG1: 182 16.3 (5.7) 16.1 (6.5) 16.5 (5.5) 15.9 (5.7) d=0.11
(specific
categories
of patients)
EG2: 185 16.4 (5.9) 18.1 (6.2) d=0.40
EG1: 182 15.2 (4.4) 16.7 (4.6) 16.5 (4.7) 16.5 (4.6) d=0.33
(fear)
EG2: 185 15.3 (4.6) 17.8 (4.7) d=0.54
Uwakwe C.B.U, et 68 - - 73 - -
al., 2000, Nigeria
Uys L, et al., 2009, 41 0.46 (0.46) 0.39 (0.43) 134 0.24 0.24 d=0.17
Lesotho, Malawi, (0.41) (0.41)
South Africa,
Swaziland,

351
Tanzania
Valois P, et al., 27 - - 47 - -
2001, Canada
Varas-Diaz N, et 269 2.79 (0.51) 2.61 (0.58/) 2.59 (0.59) 234 2.88 2.83 2.77 (0.57) d=0.40 Conhen‘d
al., 2013, Puerto (n=241) (n=206) (0.48) (0.51) (n=179) =0.29 (6-
Rico (n=219) month)
Cohen‘s d=
0.30
(12-month)
Wang Debin, et al., 69 - NA
2009, China
Williams A.B, et 208 4.1 (0.736) 4.3 (0.736) NA
al., 2006, China (empathy)
3.5 (0.736) 3.1 (0.736)
(avoidance)
0.6 (0.368) 1.2 (1.471)
(general
attitudes)
Wu S, et al., 2008, 70 - - 68 - -
China
Wu Z.Y, et al., 296 - - 270 - -
2002, China
Yiu J.W., et al., 55 2.74 (0.54) 2.27 (0.50) 2.58 (0.65) 47 2.81 2.63 2.69 (0.60) d=0.69 d=0.17
2010, Hong Kong (stigmatizing) (0.68) (0.53)
3.78 (0.78) 3.07 (0.82) 3.23 (0.91) 4.20 3.60 3.60 (1.02) d=0.62 d=0.38
(fear) (0.90) (0.87)
Young E, et al., 200 - NA
1989, U.S.

SD=√𝑁 x (upper limit – lower limit)/3.92

[Link]

352
Table 6-6 Effect size of behaviour towards PLWHA
Study Treatment group Control group Effect size
Sample Pre Post Longest Sample Pre Post Longest Pre-post Longest follow up
size (n) (mean SD) (mean follow up size (n) (mean (mean follow up effect size time point effect
SD) time point SD) SD) time point (Conhen’s d) size (Conhen’s d)
(mean SD) (mean SD)
All A.C., et al., 1997, U.S. - NA -
Arora S., et al., 2014, India -
Balogun J, et al., 1998, U.S. 26 8.9 (5.6) 9.8 (5.0) 8.4 (3.1) 23 11.2 10.4 11.0 (3.9) d=0.36 d=0.14
(3.6) (3.4)
Bluespruce J., et al., 2001, 47 - - NA
U.S.
Britton P, et al., 1999, U.S. 22 10.18 12.86 NA
(3.74) (1.94)
Buskin, SE, et al., 2002, 122 - - NA
China
Carney JS, et al., 1999, U.S.
Charuluxananan S. et al., 177 - - NA
2000, Thailand
Chisholm M, et al., 1999, - NA
U.S.
Collins P.Y., et al., 2006, - NA
South Africa
Diesel H, et al., 2013, U.S. 8 9.08 (1.5) 9.76 (0.3) 9.76 (0.5) 18 8.61 9.55 9.18 (1.2) d=0.16 d=0.07
(1.6) (0.9)
Ezedinachi E, et al., 2002, -
Nigeria
Geibel S. et al., 2017, - NA
Bangladesh
Gross E J., et al., 1993, U.S. 205 - - NA
Gutierrez J.M.M., 2014, 58 1.76 (0.62) 1.79 NA
Saudi Arabia (0.87)
Held SL, et al., 1992, U.S. 47 11.47 10.08 52 11.29 11.42 d=0.44
(3.46) (2.84) (3.74) (3.26)

353
Kamiru HN, et al., 2009, - NA
Swaziland
Kaponda CPN, et al, 2009, - NA
Malawi
Kemppamen J.K., et al., 18 - - 18 - -
1996, U.S.
Lewis DA, et al., 1996, UK NA
Li L, et al., 2013, China 880 - - 880 - -
Lohiniva A.L., et al., 2015, -
Egypt
Lueveswanij S., et al., 97 49.5% 36.9% 42 54.8% 54.8%
2000, Thailand
Mak WWS, et al., 2015, 46 41.04 44.87 43.98 (6.89) 42 40.29 45.74 44.52 (7.64) η2=.535 pre-test to follow
Hong Kong (5.53) (5.61) (7.08) (6.77) (game-based up
group) η2 =.311 (game-
based group)
η2=.516 η2 =.395 (contact
(contact group)
group)
Mahendra V.S., et al., 2006, 884 - - NA
India
McCann TV, et al., 1998, 74 - - NA
Australia
Mockiene V, et al., 2011, -
Lithuania
Nanayakkara G et al., 2017, -
SriLanka
Operario D, et al., 2016,
China
Orlander Jay, et al., 1994, -
U.S.
Pisal Hemlate, et al., 2007, - NA
India
Pulerwitz J, et al., 2015, -
Vietnam

354
Shah SM, et al., 2014, India 45 1.9 (0.9) -0.6 (9) 46 1.6 -0.3 (0.9) d=0.33
(fear HIV (change) (0.9) (change)
at work)
1.7 (1.1) -0.7 (1.0) 1.4 -0.3 (1.2) d=0.44
(fear HIV (change) (1.1) (change)
outside
work)
Stewart KE, et al., 1999, 44 - - 44 - -
UK
Stiernborg, M, et al., , 1996,
Philippines
Uwakwe C.B.U, et al., 68 - - 73 - -
2000, Nigeria
Uys L, et al., 2009, Lesotho, 41 0.42 (0.48) 0.25 NA
Malawi, South Africa, (0.35)
Swaziland, Tanzania
Valois P, et al., 2001, -
Canada
Varas-Diaz N, et al., 2013, -
Puerto Rico
Wang Debin, et al., 2009, - NA
China
Williams A.B, et al., 2006, 208 97 110 NA
China (25.750) (22.071)
Wu S, et al., 2008, China -
Wu Z.Y, et al., 2002, China 296 - - 270 - -
Yiu J.W., et al., 2010, Hong 55 4.08 (0.79) 4.73 4.40 (0.76) 47 3.88 4.26 4.21 (0.84) d=0.58 d=0.24
Kong (0.75) (0.91) (0.87)
Young E, et al., 1989, U.S. - NA

355
Table 8-1 Content validity index of the items in the questionnaire
I. Knowledge of sex workers and prostitution law (Expert panel N=6)

Item Relevant Not relevant I-CVI Interpretation

(ratings ≥ 3) (rating ≤2)
1. Do you personally know anyone who identifies as a sex worker? 6 0 1.00 Appropriate
2. Have you ever met/recognized a sex worker? 6 0 1.00 Appropriate
3. Do you have any ideas about the prostitution law in Hong Kong? 5 1 0.833 Appropriate
4. Have you ever attended a lecture, course or community forum about sex worker at any 6 0 1.00 Appropriate
time before the survey?
5. How much education you have received regarding caring for sex workers from the 5 1 0.833 Appropriate
nursing curriculum?
6. How would you rate your level of knowledge about sex workers? 6 0 1.00 Appropriate
7. In practical classes, do you feel the need to have some knowledge about sex workers? 5 1 0.833 Appropriate

356
 II. The Attitudes toward Prostitutes and Prostitution Scale (Expert panel N=6)

Item Relevant Not relevant I-CVI Interpretation S-CVI

(ratings ≥ 3) (rating ≤2)

1. Prostitution is trafficking of women 6 0 1.00 Appropriate 0.891

2. Most prostitutes are drug addicts 5 1 0.833 Appropriate
3. Prostitution is forcing undesired sexual behaviour 5 1 0.833 Appropriate
4. Prostitution is important for teaching teenage boys about sexuality 2 4 0.667 Appropriate
5. Prostitutes earn a lot of money 5 1 0.833 Appropriate
6. Prostitution allows the women who practice it to actualize their sexual
fantasies 5 1 0.833 Appropriate
7. Prostitution increases drug use in society 6 0 1.00 Appropriate
8. Most prostitutes are morally corrupt 6 0 1.00 Appropriate
9. Without prostitution more women would get raped 6 0 1.00 Appropriate
10. Most prostitutes are ugly 3 3 0.50
11. Prostitution damages society‘s morals 5 1 0.833 Appropriate
12. Prostitutes spread AIDS 6 0 1.00 Appropriate
13. Prostitution is a violation of women‘s human dignity 6 0 1.00 Appropriate
14. Prostitutes enjoy the controlling of men 5 1 0.833 Appropriate
15. Women become prostitutes because they were not properly educated 5 1 0.833 Appropriate
16. Prostitution provides men with stress relief 6 0 1.00 Appropriate
17. Prostitution is a form of violence against women 6 0 1.00 Appropriate
18. Prostitutes like sex 5 1 0.833 Appropriate
19. Many prostitutes are students who prefer a convenient, profitable job 5 1 0.833 Appropriate
20. Prostitutes are victims of drug abuse 6 0 1.00 Appropriate
21. Prostitution is a way for some women to gain power and control 6 0 1.00 Appropriate
22. Women choose to be prostitutes 6 0 1.00 Appropriate
23. Prostitution increases the rate of sexually transmitted diseases 6 0 1.00 Appropriate
24. Prostitution is a form of rape in which the victim gets paid 5 1 0.833 Appropriate
25. Prostitution harms the institution of marriage 4 2 0.667 Inappropriate
26. Most prostitutes only work as prostitutes for a few years to get settled 5 1 0.833 Appropriate

357
 financially
27. Prostitutes are unable to get out of the situation they are in 6 0 1.00 Appropriate
28. Prostitution is a way to empower economically disadvantaged populations 6 0 1.00 Appropriate
29. Through prostitution, pretty girls can find a husband 5 1 0.833 Appropriate

358
 III. Attitudes toward sex workers with HIV and sexually transmitted diseases (STDs) (Expert panel N=6)

Relevant Not relevant I-CVI Interpretation S-CVI

(ratings ≥ 3) (rating ≤2)
1. Sex workers should be legalized 6 0 1.00 Appropriate 1.00
2. Sex workers is immoral 6 0 1.00 Appropriate
3. Sex workers is a sin 6 0 1.00 Appropriate
4. There should be compulsory medical tests of sex workers 6 0 1.00 Appropriate
5. Before admission to hospital, sex workers should be routinely tested for 6 0 1.00 Appropriate
HIV/STDs
6. Sex workers who become infected with HIV/STDs deserve no sympathy 6 0 1.00 Appropriate
7. Sex workers who get HIV/STDs through their activity should have to pay for 6 0 1.00 Appropriate
medical care
8. Sex workers should be given free condoms to reduce the spread of HIV/STDs 6 0 1.00 Appropriate

359
 IV. Support for FSWs’ human rights (Expert panel N=6)

Attitudes toward sex workers’ human rights (Self-developed questionnaire based on reproductive rights and human rights standards and

principles)

Relevant Not relevant I-CVI Interpretation S-CVI

(ratings ≥ 3) (rating ≤2)
1. Sex workers have the right to nondiscrimination and equal treatment. 6 0 1.00 Appropriate 0.963
2. Sex workers have the right to life, including quality of life. 6 0 1.00 Appropriate
3. Sex workers have the right to maintain their physical integrity, without 5 1 0.833 Appropriate
fear of violence.
4. Sex workers have the right to marry and start a family. 6 0 1.00 Appropriate
5. Sex workers have the right to privacy of their personal information. 6 0 1.00 Appropriate
6. Sex workers have the right to information and education that may 6 0 1.00 Appropriate
affect their well-being.
7. Sex workers have the right to access the highest attainable standard of 6 0 1.00 Appropriate
health (physical and psychosocial).
8. Sex workers have the right to benefit from health-related scientific 5 1 0.833 Appropriate
progress.
9. Sex workers have the right to access the basic necessities (housing, 6 0 1.00 Appropriate
food, and clothing) for an adequate standard of living.

360
 V. Willingness to treat sex workers (Expert panel N=6)

Item Relevant Not relevant I-CVI Interpretation S-CVI

(ratings ≥ 3) (rating ≤2)
1. If I am allowed to choose, I will not choose to serve 6 0 1.00 Appropriate 1.00
patients who are sex workers
2. I would refuse to care for patients who are sex workers 6 0 1.00 Appropriate
3. I am willing to take care of patients who are sex workers 6 0 1.00 Appropriate

361
 VI. Cultural Competence Assessment for caring for sex workers (Expert panel N=6)

Item Relevant Not relevant I-CVI Interpretation S-CVI

(ratings ≥ 3) (rating ≤2)
For each of the following statements, select the response
that best describe how you feel about the statement:
1. Occupation is the most important factor in determining 1 5 0.167 Inappropriate 0.833
a person‘s culture
2. Sex workers think and act alike 4 2 0.667 Inappropriate
3. Many aspects of sex work influence health and health 5 1 0.833 Appropriate
care
4. Aspects of sex work need to be assessed for each 6 0 1.00 Appropriate
individual, group, and organization
5. If I know about a sex worker, I don‘t need to assess 4 2 0.667 Inappropriate
their personal preferences for health services
6. Spiritually and religious beliefs are important aspects of 5 1 0.833 Appropriate
many sex workers
7. Sex worker may identity with more than one cultural 5 1 0.833 Appropriate
group
8. Language barrier is the only difficulties for sex workers 2 4 0.333 Inappropriate
in Hong Kong
9. I believe that sex workers should be treated with respect 6 0 1.00 Appropriate
no matter what occupation
10. I understand that sex workers may define the concept of 5 1 0.833 Appropriate
―health care‖ in different ways
11. I think that knowing about sex workers helps direct my 6 0 1.00 Appropriate
work with them
For each of the following statements check the box that
best describes how often you do the following:
12. I include sex work assessment when I do individual or 5 1 0.833 Appropriate
organizational evaluations
13. I seek information on cultural needs when I identify sex 6 0 1.00 Appropriate

362
 workers
14. I have resources books and other materials available to 5 1 0.833 Appropriate
help me learn about sex workers
15. I use a variety of sources to learn about the sex workers 6 0 1.00 Appropriate
16. I ask sex workers to tell me about their own 6 0 1.00 Appropriate
explanations of health and illness
17. I ask sex workers to tell me about their expectations for 6 0 1.00 Appropriate
health services
18. I avoid using generalizations to stereotype groups of 6 0 1.00 Appropriate
sex workers
19. I recognize potential barriers to service that might be 6 0 1.00 Appropriate
encountered by sex workers
20. I remove obstacles for sex workers) when I identify 5 1 0.833 Appropriate
barriers to services
21. I remove obstacles for sex workers when people 4 2 0.667 Inappropriate
identify barriers to me
22. I welcome feedback from sex workers about how I 6 0 1.00 Appropriate
relate to sex workers from their work
23. I find ways to adapt my service to sex workers‘ 5 1 0.833 Appropriate
preference
24. I document sex work if I provide direct client service 5 1 0.833 Appropriate
25. I document the adaptations I make with sex workers if I 5 1 0.833 Appropriate
provide direct client services

363
 VII. Education needs

Item Relevant Not relevant I-CVI Interpretation

(ratings ≥ 3) (rating ≤2)
1. Do you think the topic of FSWs should be addressed in the undergraduate nursing 6 0 1.00 Appropriate
curriculum?
2. Which education approach would you prefer to acquire knowledge related to caring for 6 0 1.00 Appropriate
FSWs?

364
Table 8-2 Psychometric properties of the measurements
Measurement Cronbach’s Intra-class 95% CI
Alpha correlation
coefficient (ICC)

Attitudes toward FSWs .653 .911 .776-.965

Support for FSWs‘ human .967 .872 .668-.951
rights
Willingness to care for FSWs .745 .844 .605-.938

365
Appendix I Ethical Approval Letter for Qualitative Study of Nurses

366
Appendix II Information Sheet for Qualitative Study of Nurses

INFORMATION SHEET

A qualitative study of practicing nurses on their perceptions of female sex

workers

You are invited to participant in a study supervised by Prof. Alice Yuen Loke, Dr.
Zenobia Chan, and conducted by Haixia Ma, who is a PhD student of the school of
Nursing, The Hong Kong Polytechnic University.

The purpose of the focus group discussion is to explore practicing nurses‘ knowledge
of, attitudes towards, and willingness to provide care for female sex workers in Hong
Kong. The information collected can assist intervention programs development or
help nursing schools to make plans to improve curriculum and prepare its nursing
students responding to the diverse health care needs of the communities. The focus
group discussion will last 60-90 minutes, which will be audiotaped for future
analysis.

Risks for taking part in this study will be minimal. There will be a chance that you
may feel uncomfortable talking about female sex workers. If you feel uncomfortable
during the study, you will be allowed to terminate the interview, and you can feel
free to approach the research team for further issues related to this research after the
interview. Also, you can also seek psychological counseling from the Office of
Counseling and Wellness of the Hong Kong Polytechnic University.

Your participation is voluntary. You may refuse to participate or may withdraw

consent and discontinue the participation in the study at any time with no penalty. All
the collected data will be subjected to strict anonymity and confidentiality. Your
name will not appear on any data record sheets or publications. They will be locked
up in a secure location and only the members of the research team can have access to
this data. All the data will also be destroyed after use.

If you have any complains about the conduct of this research study, please do not
hesitate to contact Miss Cherrie Mok, Secretary of the Human Subjects Ethics Sub-
committee of the Hong Kong Polytechnic University in person or in writing (c/o
Research Office of the University) stating clearly the responsible person and
department of this study. If you would like more information about this study, please
contact Haixia Ma (email: [Link]@ , Tel: 3400-3794), or her
supervisor Prof. Alice Yuen Loke ([Link]@ , Tel：2766-6386).

Thank you for participating in this study.

Alice Yuen Loke Zenobia Chan Ma haixia

Principle Investigator, Associate Professor PhD student
Professor School of Nursing School of Nursing
School of Nursing The Hong Kong The Hong Kong
The Hong Kong Polytechnic Polytechnic University Polytechnic University
University
367
Appendix II Information Sheet for Qualitative Study of Nurses (Chinese version)

有關資料
護士對性工作者態度的研究

誠邀閣下參加由香港理工大學護理學院袁楨德教授和陳頌儀博士負責監督,香
港理工大學護理學院博士研究生馬海霞負責執行,關於「護理專業學生對性工
作者態度的研究」。

這項研究的目的是瞭解護士對性工作者態度的研究。 閣下的參與有助於我們
瞭解護士對性工作者的認識, 態度, 及將來為其服務的意願, 為初步制定減低護
理專業學生對性工作者歧視的干預措施提供依據, 並且為將來改善學校課程以
培養出滿足社區健康需求,包括滿足弱勢人群健康需求的畢業生提供資料。小
組訪談大概持續 60-90 分鐘。在討論過程中將會對討論內容進行錄音,以期為後
期的研究分析提供依據。

小組討論並沒有可預計的風險。 但閣下可能因討論性工作者而引起不安。如
遇有次情況,可示意訪問員稍緩訪問, 您有權在任何時間中止面談。如訪談中閣
下感到精神緊張或出現心理負擔, 可隨時終止訪談。 閣下訪談後有任何問題可
以向研究小組查詢。 閣下如有心理不適,亦可以向香港理工大學學生事務處預
約心理健康及輔導服務。

是次研究純屬自願性質, 閣下有充分的權利在研究開始之前或之後退出這項研
究,而不會因此受到任何不公平的待遇或被追究責任。所有參與者的資料將會
保密及加上編碼。參與者的個人身份, 絕對不會在任何研究報告或其他相關文
獻出現。所有資料,只有研究者得悉。待研究結束將對所有資料進行銷毀處理。

如果閣下對這項研究有任何不滿,可隨時親身或書面與香港理工大學人類實驗
物件操守小組委員會秘書莫小姐聯絡(位址:香港理工大學研究事務處轉交)。
如果閣下想獲悉更多有關這項研究的資料,請與香港理工大學護理學院博士研究
生馬海霞(電郵:[Link]@ , 電話:3400-3794), 或者袁楨德博士(電
郵:[Link]@ , 電話:2766-6386 聯絡)。

謝謝閣下有興趣參與這項研究。

袁桢德教授 陳頌儀博士 馬海霞女士

主要研究员
香港理工大学护理学院 香港理工大学护理学院 香港理工大学护理学院

368
Appendix III Consent Form for Qualitative Study of Nurses

CONSENT TO PARTICIPATE IN RESEARCH

A qualitative study of practicing nurses on their perceptions of female sex

workers

I hereby consent to participate in the captioned research

supervised by Prof. Alice Yuen Loke, Dr. Zenobia Chan, and conducted by Ms.
Haixia Ma, a PhD student.

I understand that information obtained from this research may be used in future
research and published. However, my right to privacy will be retained, i.e., my
personal details will not be revealed.

The procedure as set out in the attached information sheet has been fully explained. I
understand the benefits and risks involved. My participation in the project is
voluntary.

I acknowledge that I have the right to question any part of the procedure and can
withdraw at any time without penalty of any kind.

Name of the participant Signature of the participant Date

Name of the researcher Signature of the researcher Date

Name of the witness Signature of the witness Date

369
Appendix III Consent Form for Qualitative Study of Nurses (Chinese Version)

参与研究同意书
護士對性工作者態度的研究

本人 同意參加由香港理工大學護理學院袁楨德教授和陳頌儀博士
負責監督,香港理工大學護理學院博士研究生馬海霞負責執行的研究專案。

本人清楚明白此計畫所獲得的資料,有機會被用於未來的研究及發表。 然而本
人的個人資料會絕對保密,完全保留私隱權利。

本人對所附的計畫詳情已經十分清楚, 明白當中涉及的一切利益及風險。 本人
是自願參與這項研究。

本人理解有權在研究過程中提出問題,並在任何時候決定退出研究而不會受到
任何不正常的待遇或被追究責任。

參與者姓名 參與者簽署 日期

研究員姓名 研究員簽署 日期

見證人姓名 見證人签署 日期

370
Appendix IV Ethical Approval Letter for Qualitative Study of Female Sex
Workers

371
Appendix V Information Sheet for Qualitative Study of Female Sex Workers

Information Sheet for Individual Interview among Female Sex Workers

INFORMATION SHEET

A qualitative study of the experience of female sex workers in accessing health

care services
You are invited to participant in a study supervised by Prof. Alice Yuen Loke, and
conducted by Haixia Ma, who is a PhD student of the School of Nursing, The Hong
Kong Polytechnic University.

The purpose of the individual interview study is to explore the experience of sex
workers in accessing healthcare services in Hong Kong. The information collected
can assist the health care professionals to understand the facilitators and barriers that
influence sex workers‘ access to and experience of health care services in Hong
Kong. The findings of the study will contribute to the development of stigma
reduction intervention programs to facilitate of access of sex workers to health care
services. The individual interview will last around 60 minutes.

Risks for taking part in this study will be minimal. There will be a chance that
participants may feel uncomfortable talking about negative healthcare service
experience. If participant feel uncomfortable during or after the study, social workers
from the NGO will help to provide psychological counseling service at free of
charge to respond to any negative reactions.

Participation in this study is voluntary. Participants may refuse to participate or may

withdraw consent and discontinue the participation in the study at any time with no
penalty. All the collected data will be subjected to strict anonymity and
confidentiality. Participants‘ name will not appear on any data record sheets or
publications. The data will be locked up in a secure location and only the members
of the research team can have access to this data. All the data will also be destroyed
after use.

If participants have any complains about the conduct of this research study, please do
not hesitate to contact Miss Cherrie Mok, Secretary of the Human Subjects Ethics
Sub-committee of the Hong Kong Polytechnic University in person or in writing (c/o
Research Office of the University) stating clearly the responsible person and
department of this study. If you would like more information about this study, please
contact Haixia Ma (email: [Link]@ , Tel: 3400-3794), or her
supervisor Prof. Alice Yuen Loke ([Link]@ , Tel：2766-6386).

Thank you for participating in this study.

Alice Yuen Loke Ma haixia

Principle Investigator, Professor PhD student
School of Nursing School of Nursing
The Hong Kong Polytechnic University Hong Kong Polytechnic University

372
Appendix V Information Sheet for Qualitative Study of Female Sex Workers
(Chinese version)

有關資料
性工作者就醫經歷的研究

誠邀閣下參加由香港理工大學護理學院袁楨德教授負責監督,香港理工大學護
理學博士研究生馬海霞負責執行，關於「性工作者就醫經歷的研究」
。

這項研究的目的是瞭解性工作者的就醫經驗。閣下的參與有助於我們瞭解性工
作者醫療服務的需要及就醫障礙,並為初步制定減低護理專業學生對性工作者
歧視的干預措施提供依據, 並且為將來改善及滿足社區健康需求,包括滿足弱勢
人群健康需求的資料。訪談大概持續 60 分鐘。

參加面談並沒有可預計的風險。但閣下可能因憶述受歧視地經歷及不公平的待
遇而引起不安。如遇有次情況,可示意訪問員稍緩訪問,您有權在任何時間中止
面談。如訪談中或訪談後閣下感到精神緊張或出現心理負擔,紫藤社工會提供
免費心理輔導。

是次研究純屬自願性質, 閣下有充分的權利在研究開始之前或之後退出這項研
究, 而不會因此受到任何不公平的待遇或被追究責任。所有參與者的資料將會
保密及加上編碼。參與者的個人身份,絕對不會在任何研究報告或其他相關文
獻出現。所有資料,只有研究者得悉。待研究結束將對所有資料進行銷毀處理。

如果閣下對這項研究有任何不滿,可隨時親身或書面與香港理工大學人類實驗
物件操守小組委員會秘書莫小姐聯絡(位址:香港理工大學研究事務處轉交)。如
果閣下想獲悉更多有關這項研究的資料,請與香港理工大學護理學院博士研究生
馬海霞(電郵:[Link]@ , 電話:3400-3794), 或者袁楨德博士(電
郵:[Link]@ , 電話:2766-6386 聯絡)。

謝謝閣下有興趣參與這項研究。

袁桢德教授 馬海霞女士

主要研究員 香港理工大學護理學院
香港理工大學護理學院

373
Appendix VI Consent Form for Qualitative Study of Female Sex Workers

CONSENT TO PARTICIPATE IN RESEARCH

Experience of health care services among
female sex workers in Hong Kong: a qualitative study

I hereby consent to participate in the captioned research

supervised by
Prof. Alice Yuen Loke, and conducted by Haixia Ma.

I understand that information obtained from this research may be used in future
research and published. However, my right to privacy will be retained, i.e., my
personal details will not be revealed.

The procedure as set out in the attached information sheet has been fully explained. I
understand the benefits and risks involved. My participation in the project is
voluntary.

I acknowledge that I have the right to question any part of the procedure and can
withdraw at any time without penalty of any kind.

Name of the participant Signature of the participant Date

Name of the researcher Signature of the researcher Date

Name of the witness Signature of the witness Date

374
Appendix VI Consent Form for Qualitative Study of Female Sex Workers
(Chinese version)

参与研究同意书
性工作者就醫經歷的研究

本人 同意參加由香港理工大學護理學院袁楨德博士負責監督,香港
理工大學護理學院博士研究生馬海霞負責執行的研究專案。

本人清楚明白此計畫所獲得的資料,有機會被用於未來的研究及發表。 然而本
人的個人資料會絕對保密,完全保留私隱權利。

本人對所附的計畫詳情已經十分清楚, 明白當中涉及的一切利益及風險。 本人
是自願參與這項研究。

本人理解有權在研究過程中提出問題,並在任何時候決定退出研究而不會受到
任何不正常的待遇或被追究責任。

參與者姓名 參與者簽署 日期

研究員姓名 研究員簽署 日期

見證人姓名 見證人签署 日期

375
Appendix VII Ethical Approval Letter for Cross-Sectional Study of Nursing
Students

376
Appendix VIII Information Sheet for Cross-Sectional Study Among Nursing
Students

INFORMATION SHEET

Nursing students’ knowledge, attitudes, and education need in caring for sex

workers in Hong Kong: a cross-sectional survey

You are invited to participant in a study supervised by Prof. Alice Yuen Loke, and
conducted by Haixia Ma, who is a PhD student of the school of Nursing, The Hong
Kong Polytechnic University.

The purpose of the cross-sectional study is to explore undergraduate nursing students‘

knowledge of, attitudes towards, and education needs in caring for sex workers in
Hong Kong. The information collected can assist intervention programs development
or help nursing schools to make plans to improve curriculum and prepare its nursing
students responding to the diverse health care needs of the communities. It will take
15-20 minutes to complete the survey.

Risks for taking part in this study will be minimal. There will be a chance that you
may feel uncomfortable when answering questions about female sex workers. If you
feel uncomfortable during the study, you will be allowed to terminate the interview,
and you can feel free to approach the research team for further issues related to this
research after the interview. Also, you can also seek psychological counseling from
the Office of Counseling and Wellness of the Hong Kong Polytechnic University.

Your participation is voluntary. You may refuse to participate or may withdraw

consent and discontinue the participation in the study at any time with no penalty. All
the collected data will be subjected to strict anonymity and confidentiality. Your
name will not appear on any data record sheets or publications. They will be locked
up in a secure location and only the members of the research team can have access to
this data. All the data will also be destroyed after use.

If you have any complains about the conduct of this research study, please do not
hesitate to contact Miss Cherrie Mok, Secretary of the Human Subjects Ethics Sub-
committee of the Hong Kong Polytechnic University in person or in writing (c/o
Research Office of the University) stating clearly the responsible person and
department of this study. If you would like more information about this study, please
contact Haixia Ma (email: [Link]@ , Tel: 3400-3794), or her
supervisor Prof. Alice Yuen Loke ([Link]@ , Tel：2766-6386).

Thank you for participating in this study.

Alice Yuen Loke Ma haixia

Principle Investigator, Professor PhD student
School of Nursing School of Nursing
The Hong Kong Polytechnic University The Hong Kong Polytechnic
University

377
Appendix VIII Information Sheet for Cross-Sectional Study Among Nursing
Students (Chinese version)

有關資料
護理專業學生對性工作者的知識，態度，文化能力和教育需求方面的研究

誠邀閣下參加由香港理工大學護理學院袁楨德教授和陳頌儀博士負責監督,香
港理工大學護理學院博士研究生馬海霞負責執行,關於「護理專業學生對性工
作者的知识，態度，和教育需求方面的研究」
。

這項研究的目的是瞭解護理專業學生對性工作者的知识，態度，和教育需求方
面的研究。 閣下的參與有助於我們瞭解護理專業學生對性工作者的認識, 態度,
及將來為其服務的意願, 為初步制定減低護理專業學生對性工作者歧視的干預
措施提供依據, 並且為將來改善學校課程以培養出滿足社區健康需求,包括滿足
弱勢人群健康需求的畢業生提供資料。此問卷大約需要 15-20 分鐘。

本研究並沒有可預計的風險。 但閣下可能因問及性工作者而引起不安。如遇
有次情況,可示意訪問員稍緩訪問, 您有權在任何時間中止問卷調查。如問卷調
查中閣下感到精神緊張或出現心理負擔, 可隨時終止問卷調查。 閣下問卷調查
後有任何問題可以向研究小組查詢。 閣下如有心理不適,亦可以向香港理工大
學學生事務處預約心理健康及輔導服務。

是次研究純屬自願性質, 閣下有充分的權利在研究開始之前或之後退出這項研
究,而不會因此受到任何不公平的待遇或被追究責任。所有參與者的資料將會
保密及加上編碼。參與者的個人身份, 絕對不會在任何研究報告或其他相關文
獻出現。所有資料,只有研究者得悉。待研究結束將對所有資料進行銷毀處理。

如果閣下對這項研究有任何不滿,可隨時親身或書面與香港理工大學人類實驗
物件操守小組委員會秘書莫小姐聯絡(位址:香港理工大學研究事務處轉交)。
如果閣下想獲悉更多有關這項研究的資料,請與香港理工大學護理學院博士研究
生馬海霞(電郵:[Link]@ ,電話:3400-3794),或者袁楨德博士(電
郵:[Link]@ , 電話:2766-6386 聯絡)。

謝謝閣下有興趣參與這項研究。

袁桢德教授 馬海霞女士
主要研究员
香港理工大学护理学院 香港理工大学护理学院

378
Appendix IX. Consent Form for Cross-Sectional Study Among Nursing students

CONSENT TO PARTICIPATE IN RESEARCH

Nursing students’ knowledge, attitudes, cultural competence and education

need in caring for sex workers in Hong Kong: a cross-sectional survey

I hereby consent to participate in the captioned research

supervised by Prof. Alice Yuen Loke, and conducted by Ms. Haixia Ma, a PhD
student.

I understand that information obtained from this research may be used in future
research and published. However, my right to privacy will be retained, i.e., my
personal details will not be revealed.

The procedure as set out in the attached information sheet has been fully explained. I
understand the benefits and risks involved. My participation in the project is
voluntary.

I acknowledge that I have the right to question any part of the procedure and can
withdraw at any time without penalty of any kind.

Name of the participant Signature of the participant Date

Name of the researcher Signature of the researcher Date

Name of the witness Signature of the witness Date

379
Appendix IX. Consent Form for Cross-Sectional Study Among Nursing students

(Chinese Version)

参与研究同意书
護理專業學生對性工作者的知識，態度，文化能力和教育需求方面的研究
本人 同意參加由香港理工大學護理學院袁楨德教授負責監督,香港
理工大學護理學院博士研究生馬海霞負責執行的研究專案。

本人清楚明白此計畫所獲得的資料,有機會被用於未來的研究及發表。 然而本
人的個人資料會絕對保密,完全保留私隱權利。

本人對所附的計畫詳情已經十分清楚, 明白當中涉及的一切利益及風險。 本人
是自願參與這項研究。

本人理解有權在研究過程中提出問題,並在任何時候決定退出研究而不會受到
任何不正常的待遇或被追究責任。

參與者姓名 參與者簽署 日期

研究員姓名 研究員簽署 日期

見證人姓名 見證人签署 日期

380
Appendix X Interview guide of the qualitative interview among nurses_English

version

Part I. Characteristics of the participants

1. Age:
2. Gender
a. Male
b. Female
3. Place of birth:
4. Marital status
a. Single (live alone)
b. Single (living with boyfriend/non-paying partner)
c. Married
d. Separated
e. Divorced
f. Widowed
5. Program
a. Master of Science in Nursing
b. Master of Science in Infection Control
c. Master of Science in Mental Health Nursing
d. Doctor of Health Science/ Doctor of Health Science (Nursing)
e. Others, please specify:
6. Year of study
a. Year one
b. Year two
c. Year three
d. Year four
e. Others, please specify:
7. Religion

381
 a. Christian

b. Muslim

c. Catholic

d. Buddhist

e. Atheist

f. Agnostic

g. Non-religious

h. Others, please specify:

8. Type of housing

a. Private house

b. Public house

c. Rent house

d. Others

9. Family monthly income

a. < 10,000
b. 10,000-20,000
c. 20,000-30,000
d. 30,000-40,000
e. >40,000
10. Types of working organization (hospital/clinics)
a. Public
b. Private
c. NGO
d. Others, please specify:

Part II. Nursing practice and training

1) How many years have you worked as a registered nurse or enrolled nurse?

years

382
 2) Types of nursing

a. General nurse

b. Mental health nurse

3) Which unit are you working in?

4) Have you ever received sex-work related teaching/training?

a. Yes
If yes, please specify:
1) Undergraduate
2) Hospital
3) Continuing Nursing Education
4) Others:
b. No

Part II Qualitative interview guide among nurses

1. Can we start by sharing with me what a typical day at work is like for you

and what kind of patients and problems you encounter?

2. Can you recall a suspected sex worker in your work unit?

Prompting questions: Can you describe the patient? How did the patient

appear to you that led you suspect s/he may involve in sex work? What made

you think....? Can you tell me more about....? What did you do about...?

383
 Target question(s) to get at the 'core' of your concerns about stigma with sex

workers:

3. How do you manage concerns when you suspect the patient is a sex worker?

Prompting questions: What goes through your mind as you try to provide

care for the patient? Can you tell me more about the concerns or discomfort

you feel? What did you do when....?

4. How do you feel after working with those you suspect are sex workers?

Prompting questions: How did you come to feel that way? What makes it

difficult to help patients in this situation? Can you tell me more about...?

5. How do you feel about providing sex worker-related training to nursing

students/nurses?

384
Appendix XI Interview guide of the qualitative study of nurses (Chinese version)

第一部分. 人口學資料

1. 年齡:

2. 性別

a. 男

b. 女

4. 出生地:

5. 婚姻狀態

a. 單身 (獨居)

b. 單身(同居)

c. 已婚

d. 分居

e. 離異

f. 喪偶

6. 學歷/就讀課程

a. 護理學碩士

b. 感染控制碩士

c. 護理學碩士（精神科）

d. 護理學博士

e. 其他,請列明:

7. Religion

a. 基督教

b. 天主教

c. 佛教

d. 無神論者

385
 e. 不可知主義

f. 無宗教信仰

8. 其他， 請列明：

9. 房屋類型

a. 私人屋苑

b. 公共房屋（公屋，居屋）

c. 租住房屋

d. 其他
10. 家庭月收入
a. < 10,000
b. 10,000-20,000
c. 20,000-30,000
d. 30,000-40,000
e. >40,000
11. 工作機構類型(醫院/診所)
a. 公立醫院
b. 私家醫院
c. 非政府組織
d. 其他， 請列明:

Part II. 護士經歷/培訓

1) 請問您做註冊護士/登記護士已經有多少年了？

2) 護士類別

c. 普通科護士

d. 精神科護士

3) 請問您工作的部門?

386
 4) 請問您是否接受過性工作者方面的培訓?

a. 有
如果有，請列明時間
1) 本科期間
2) 醫院培訓
3) 護理持續教育
4) 其他:
c. 沒有

第二部分. 訪談
多謝大家參與我們這個研究。我們將會討論一個比較敏感，很少公開討論，但
有十分重要的話題。所以， 大家有權選擇中止或者拒絕回答我任何問題。但
是研究團隊會保證大家所說的任何內容都絕對保密，絕對不會向你們的工作單
位洩露。同樣，我想強調任何意見並無對錯之分。我們的討論，並非評論你的
工作，而是希望通過此研究，幫助護士在面臨一些困難或特別的病人的時候，
能夠從容應對。

所以，討論的內容可能有些敏感，希望大家盡可能多的分享你們的寶貴意見和
感受。我可以將我們的對話錄音嗎，這樣我可以專注在我們的談話上，而不是
做筆記。

大家可以先
1. 以你們最平常的一天開始吧。平時你們的工作是什麼樣的？面臨的是哪
些病人？你工作中最常遇到的問題都有哪些？
2. 你能否回憶起一些有性病的病人，或者懷疑她有性病的病人？
可不可以描述一下那個病人？從哪些方面，你開始懷疑這個病人有性病？
你為什麼這麼懷疑？可否講多 D?
3. 當你懷疑病人有性病的時候，你的心態是什麼樣的？
當你為這類病人提供護理服務的時候，你心裡怎麼想的？你的猶豫，你
的不舒服可否講多些？當你服務的時候，你怎麼做的？關於性工作者，
你從哪些得知的？
4. 為一些懷疑/疑似性工作者服務後，你什麼感覺？

387
 哪些方面你覺得自己很難為她們服務？可否講多 D

我簡單總結一下。。。

5. 關於這個課題，你還有什麼其他的意見或看法嗎

謝謝大家的參與，你的時間和幫助對我的研究十分重要。

388
Appendix XII Interview guide of the individual interview among female sex

workers (English version)

Part I. Characteristics of the participants

1. Age:

2. Place of birth:

3. If you were not born in Hong Kong, how long have you been living in

Hong Kong:

years

4. Education level

a. Primary education or below

b. Junior secondary education

c. Senior secondary education

d. Post-secondary non-tertiary education

e. Tertiary education or above

5. Marital status

a. Single (live alone)

b. Single (living with boyfriend/non-paying partner)

c. Married

d. Separated

e. Divorced

f. Widowed

6. Type of housing

2）Public housing estate

3）Home ownership scheme

4）Private house
389
 5）Rent house

6）Villa

7）Traditional village hourse

8）Others

7. Total number of pregnancy:

Including: No. of birth of the child ;

No. of miscarriage ;

No. of induced abortion ;

No. of stillbirth ;

Other:

8. How many children do you have?

a. None

b. One

c. Two

d. Three or more

9. How about your relationship with your children (If you have children)

a. Very close

b. Good

c. Fair

d. Bad

10. Do your children know that you are working in the sex industry?

a. Yes

b. No

c. Not sure

11. Who else lives together with you?

390
 a. Husband

b. Boyfriend

c. Mother/father

d. Father/mother in-law

e. Other sex worker

f. Others:

Part II. Sex work

1. How old were you when you start to work as a sex worker?

(years old)

2. Why did you choose to work as a sex worker?

3. Where do you currently work?

a. One women brothel

b. Karaoke bar

c. Bars

d. Saunas and massage parlor

e. Night club

f. Hotels

g. Street

h. Others, please specify:

4. Average number of client/week: (client/week)

5. Price per intercourse (HK Dollar)

a. <100

b. 101-300

c. 301-500

391
 d. >500

6. Motherly household income (HK Dollar)

a. <10,000

b. 10,001-15,000

c. 15,001-20,000

d. >20,000

7. Condom use frequency with clients: %

Condom frequency with boyfriend/partner/husband: %

Part III. Health status

1. Do you smoke?

a. Yes

If yes, No. of cigarette/day:

b. No

2. How often do you drink?

a. Almost every night

b. Every week

c. Every two weeks

d. Every month

e. I don‘t drink

3. Have you ever been diagnosed with any sexually transmitted diseases

(STDs)?

a. Never

b. HIV/AIDS

c. Syphilis

d. Chlamydia

e. Gonorrhea
392
 f. Genital warts

g. Human papillomavirus (HPV)

h. Herps

i. Hepatitis B

i. Others, please specify:

4. Do you have been diagnosed with other disease? If yes, please specify:

5. Self perceived health status:

a. Excellent /very good

b. Good

c. Fair

d. Poor

6. If you have any children, how about the health of the children?

a. Excellent/very good

b. Good

c. Fair

d. Poor

7. In the past one month, have you ever used the health care services?

a. Yes

b. No

8. If yes, where did you obtain the health care services?

a. Non-governmental organization/outreach services

b. Public hospital/clinic

c. Private hospital/clinic

d. Traditional Chinese medicine

e. Others, please specify:

393
 9. If no, where do you think you would prefer to get the health care services?

a. Non-governmental organization/outreach services

b. Public hospital/clinic

c. Private hospital/clinic

d. Traditional Chinese medicine

e. Others, please specify:

10. Reasons of using the health care services

a. Medical consultation/advice

b. HIV/STD testing and treatment

c. Pap smear test

d. Psychological counseling

e. Termination of pregnancy

f. Violence (e.g. sexual violence)

g. Substance abuse treatment

h. Others, please specify:

11. Overall health care service experience

a. Excellent

b. Good

c. Fair

d. Poor

Qualitative interview guideline

Part III. Warm up questions

1) First, I would like to get to know you better. Could you introduce yourself?

a. How long have you lived here?

b. What do you do in a typical day?

394
 c. What are your working hours? How many days a week?

d. How do you describe your job? Can you describe the positive and negative

aspects of your job, and give some examples?

e. How is your relationship with your children? Perceived supports from them

or supports for them?

2) Healthcare needs

a. How do you describe your health? How important is health to you?

b. In your experience what illnesses do you think are most common with sex

workers? Which types of health care services do you think is the best suitable

for you?

c. What are your goals for health? How would you try to reach health goals?

3) Healthcare access

a. If needed, which types of health care services you would like to choose? (e.g.

public, private or NGO) Why?

b. In your experience, how does your sex work affect your access to health care?

c. What do you see as the biggest problem in accessing healthcare services for

female sex workers in Hong Kong?

4) Health care services experiences

a. As a sex worker, in what ways do you think your experience of your health

care services might be different to people who do not identify as sex workers?

How might that have been different?

b. Could you describe your experience of accessing health care service? (e.g.

happy or unhappy experience)

395
 c. When you discuss you, your life, and what matters to you with your health
care providers, do you think your sex work should be part of that discussion?
Why? How?
d. How do you feel about being asked directly/suspected about your sex work?

e. Overall, how do you evaluate the health care services provided by the

doctors/nurses?

5) Attitude towards sex work-related stigma reduction intervention among

nursing students

a. Could you offer some suggestions on current health care services?

b. What should we teach health care providers?

c. What would you like to suggest on becoming a better nurse?

d. How do you feel about the idea of workshop between sex work and nurse to

increase mutual understanding and reduce stigma?

e. Is there anything you‘d like to add?

Thank you!

396
Appendix XIII Interview guide of the individual interview among female sex

workers (Chinese version)

第一部分：個人資料
1. 年齡：
2. 出生地：
a) 香港
b) 中國大陸
c) 其他：
3. 【只問非香港出生者】咁你黎左香港幾耐？
4. 教育程度
a) 小學或以下 d) 專上非學位
b) 初中 e) 大學或以上
c) 高中

5. 婚姻狀況
a) 單身 d) 分居
b) 單身（同居） e) 離異
c) 已婚 f) 喪偶

6. 房屋類型
a) 公屋 b) 村屋：別墅/平房/新型村屋
c) 居屋 d) 村屋：建設磚石蓋搭建築物/傳統村屋
e) 私人住宅單位 f) 其他
g) 租住房屋

7. 共有 次懷孕
其中包含 次分娩; 次自然流產; 次人工流產;
次死產

8. 您有幾個孩子？
a) 沒有
b) 1 個
c) 2 個
d) 3 個以上
9. 如果有子女，您和子女關係怎麼樣？
a) 很好，很親密
b) 好
c) 一般
d) 很不好
10. 您子女是否知道您從事性工作？
a) 知道

397
 b) 不知道
c) 不肯定
11. 您現在和誰一起生活？（可多選）
a) 獨自生活
b) 父母
c) 丈夫
d) 男朋友
e) 子女
f) 同行姐妹
g) 其他：

第二部分： 工作情況
1. 您從事性工作大約多久了？ （年）
2. 您從事性工作的原因?

3. 目前您的工作地點？
a) 一樓一
b) 卡拉 OK
c) 酒吧
d) 桑拿足浴
e) 夜總會
f) 酒店
g) 街道
h) 其他，請列明：

4. 平均每周有幾個客人？ （客人/周）

5. 平均家庭月收入 （港幣）
a. <10,000
b. 10,001-15,000
c. 15,001-20,000
d. >20,000

6. 每次服務收費約多少（港幣）？

平均月收入約多少（港幣）？

398
 7. 安全套使用頻率
a) 與客人 %; b) 與男朋友/配偶 %

第三部分：健康情况
1. 是否吸煙
a) 是 支/天
b) 否

2. 是否飲酒
a) 是
 每天  每週  每兩周  每個月
b) 否

3. 您曾經是否患有任何性病？
a) 從來沒有
b) 愛滋病
c) 梅毒
d) 淋病
e) 衣原體感染
f) 支原體感染
g) 尖銳濕疣（椰菜花）
h) 人類乳頭瘤病毒
i) 生殖器皰疹
j) 乙肝
k) 其他，請列明

4. 您是否患有其他疾病？如果有，請列明：

5. 您對自己目前的健康狀況評價
a) 非常好
b) 好
c) 一般
d) 差
6. 如果有子女，您對子女的健康情況評價

399
 a) 非常好
b) 好
c) 一般
d) 差
7. 過去的一個月內，您有沒有使用過香港的醫療服務？
a) 有
b) 沒有
8. 如果您曾經使用過香港的醫療服務，請問使用過哪種類型的醫療服務？
a) 非政府組織/外展服務
b) 公立醫院/診所
c) 私家醫院/診所
d) 中醫服務
e) 其他，請列明：
9. 如果未曾使用過香港的醫療服務，假如將來生病或健康檢查，您將會
選擇哪種類型的醫療服務？
a) 非政府組織/外展服務
b) 公立醫院/診所
c) 私家醫院/診所
d) 中醫服務
e) 其他，請列明
10. 使用醫療服務的原因 （可多選）
a) 醫療諮詢/建議
b) 愛滋病/性病檢測或治療
c) 子宮頸抹片檢查
d) 心理輔導
e) 終止妊娠
f) 暴力（例如性暴力）
g) 美沙酮治療服務
h) 其他，請列明
11. 整体来讲，您对医疗服务的评价
a. 非常好
b. 好
c. 一般
d. 差

400
第四部分：訪談
1） 首先，我想進步一步瞭解您。你可否簡單自我介紹一下？（熱身問
卷）
a) 您來香港多久了？
b) 您生命中最重要的人是誰？
c) 您同您子女關係怎麼樣？
d) 您為什麼選擇性工作這個行業？
e) 可否描述一下您最平常的一天？
f) 您怎麼看待自己，怎麼看待自己的這份工作？可否跟我們分
享您工作中開心或者不開心的事情嗎？
g) 您覺得其他人怎麼看待你？
h) 將來您有什麼打算？
2） 健康需求
a) 您覺得自己的健康狀況怎麼樣？健康對您有幾重要？
b) 對性工作者來講，哪種疾病最常見？最需要哪種醫療服務？
c) 您有哪些健康方面的目標? 您怎麼做，才能達到這些目標?
3） 醫療途徑
a) 如果有需要，您選擇哪種醫療機構就醫？（公立，私立醫院
或 NGO），原因？
b) 性工作如何影響你求醫？
c) 您認為香港性工作者在求醫方面有哪些困難或障礙？
4） 醫療服務
a) 比較性工作者與非性工作所接受的醫療服務，是否有任何不
同？如果有不同，您覺得是什麼原因造成的？
b) 您可否描述一下您曾經的求醫經歷嗎？（開心或不開心的經
歷）
c) 求診時，你覺得是否有必要談起性工作？為什麼？如何談起
呢？
d) 假如醫護人員直接問/懷疑你是否從事性工作，你將會是什麼
感受？
e) 整體來講，您覺得醫生/護士對你的態度怎麼樣？
5） 醫療護理服務及教育方面的建議
a) 您對目前的醫療服務有哪些建議？
b) 我們應該教授醫護人員哪些方面的知識？
c) 您心中醫護人員應該具備哪些素質或能力？

401
 d) 如果有工作坊，目的是增進性工作者和護士的互相瞭解，您
怎麼看待？
e) 您是否還有內容需要補充？

多謝參與！

402
Appendix XIV Questionnaire of the cross-sectional survey among nursing
students

Part I. Characteristics of the participants

1. Age

a. 18

b. 19

c. 20

d. 21

e. 22

f. 23

g. >23

2. Gender

c. Male

d. Female

3. Place of birth

a. Hong Kong

b. Mainland, China

c. Overseas

4. Which year in bachelor of nursing programme are you?

f. Year one

g. Year two

h. Year three

i. Year four

j. Year five

5. Types of nursing programmes

a. General nursing

403
 b. Mental health nursing

6. Religion

i. Christian

j. Muslim

k. Catholic

l. Buddhist

m. Atheist

n. Agnostic

o. Non-religious

p. Others

7. District of resident
a. Island b. Kwai Tsing
c. North d. Sai Kung
e. Sha Tin f. Tai Po
g. Tsuen Wan h. Tuen Mun
i. Yuen Long j. Kowloon City
k. Kwun Tong l. Sham Shui Po
m. Wong Tai Sin n. Yau Tsim Mong
o. Central & Western p. Eastern
q. Southern r. Wan Chai

Part II. Knowledge of sex work and prostitution law

1. Do you personally know anyone who identifies as a sex worker?
a. Family member
b. Friend
c. Acquaintance (People who you are familiar with)
d. Classmates
e. Neighbour
f. Other
g. No
2. Have you ever seen somebody who you recognized as a sex worker?

404
 a. Yes
b. No
c. I am not sure
3. Rank top five the most influential factors on your attitudes toward sex
workers?

Ranking
a. The attitudes of my family
b. The attitudes of my friends
c. My school education
d. The attitudes of clinical
instructor
e. The media
f. The culture
g. The social atmosphere about
sex workers
h. The religion
i. Nursing code of ethics of
providing fair and equal
treatment to all patients
j. Personal positive experience
with sex workers
k. Personal negative
experience with sex workers
h. Others, please specify

4. Prostitution is defined as the exchange of sex for money or goods.

Which one of the following is true?
a. Prostitution is legal in Hong Kong
b. Prostitution is illegal in Hong Kong
c. Prostitution is not illegal in Hong Kong
d. I have no ideas
5. In your opinion, is it morally acceptable or morally unacceptable to

buy sex?
(1 for ―Totally morally acceptable‖ to 10 for ―Totally morally unacceptable‖.)

Totally morally acceptable Totally morally

unacceptable
1 2 3 4 5 6 7 8 9 10

405
6. In your opinion, is it morally acceptable or morally unacceptable to

sell sex?
(1 for ―Totally morally acceptable‖ to 10 for ―Totally morally unacceptable‖.)

Totally morally acceptable Totally morally

unacceptable
1 2 3 4 5 6 7 8 9 10

7. Have you ever attended a lecture, course or community forum about sex
worker at any time before the survey?
a. Yes
b. No
c. I can‘t remember
8. How would you rate your level of knowledge about sex workers?
a. No knowledge
b. Low level
c. Average level
d. High level
e. Very high level
9. How many hours of education you have received regarding caring for
sex workers?
a. None
b. 1-5 hours
c. 6-10 hours
d. 11-15 hours
e. 16-20 hours
f. >20 hours
10. Do you feel the need to have knowledge about sex workers?
a. Yes, I am interested in this topic and want to have a lot of knowledge
about sex workers.
b. Yes, I want to have some knowledge about sex workers.
c. Yes, I want to have a little knowledge about sex workers.
d. No, I have no interest in such topic.
e. I am not sure
11. When taking a patient history, will you specifically encourage disclosure
of possible sex worker identity?

406
a. Yes
b. No
c. I am not sure

407
Part III Attitudes
a) The Attitudes toward Prostitutes and Prostitution Scale

Item Strongly Disagree Neutral Agree Strongly

disagree agree
1 2 3 4 5

1. Prostitution is trafficking
of women
2. Most prostitutes are drug
addicts
3. Prostitution is forcing
undesired sexual
behaviour, for example,
forced sex without a
condom.
4. Prostitution is important
for teaching teenage boys
about sexuality
5. Prostitutes earn a lot of
money
6. Prostitution allows the
women who practice it to
actualize their sexual
fantasies
7. Prostitution increases drug
use in society
8. Most prostitutes are
morally corrupt
9. Without prostitution more
women would get raped
10. Most prostitutes are ugly

11. Prostitution damages

society‘s morals
12. Prostitutes spread AIDS

13. Prostitution is a violation

of women‘s human dignity
14. Prostitutes enjoy the
controlling of men
15. Women become prostitutes
because they were not
properly educated
16. Prostitution provides men
with stress relief
17. Prostitution is a form of
violence against women
18. Prostitutes like sex

19. Many prostitutes are

students who prefer a
convenient, profitable job

408
20. Prostitutes are victims of
drug abuse
21. Prostitution is a way for
some women to gain
power and control
22. Women choose to be
prostitutes
23. Prostitution increases the
rate of sexually transmitted
diseases
24. Prostitution is a form of
rape in which the victim
gets paid
25. Prostitution harms the
institution of marriage
26. Most prostitutes only work
as prostitutes for a few
years to get settled
financially
27. Prostitutes are unable to
get out of the situation they
are in
28. Prostitution is a way to
empower economically
disadvantaged populations
29. Through prostitution,
pretty girls can find a
husband

409
b) Attitudes toward sex workers with HIV and sexually transmitted diseases
(STDs)
Strongly Disagree Neutral Agree Strongly
disagree agree
1 2 3 4 5

1. Sex workers should be

legalized
2. Sex workers are immoral

3. Sex worker is a sin

4. There should be compulsory

medical tests of sex workers
5. Before admission to
hospital, sex workers should
be routinely tested for
HIV/STDs
6. Sex workers who become
infected with HIV/STDs
deserve no sympathy
7. Sex workers who get
HIV/STDs through their
activity should have to pay
for medical care
8. Sex workers should be
given free condoms to
reduce the spread of
HIV/STDs

c) Attitudes toward sex workers’ human rights

Items Strongly Disagree Neutral Agree Strongly

disagree agree
1. Sex workers have the right
to nondiscrimination and
equal treatment
2. Sex workers have the right
to life, including quality of
life
3. Sex workers have the right
to maintain their physical
integrity, without fear of
violence
4. Sex workers have the right
to marry and start a family
5. Sex workers have the right
to privacy of their personal
information
6. Sex workers have the right
to information and education

410
 that may affect their well-
being
7. Sex workers have right to
access the highest attainable
standard of health (physical
and psychosocial)
8. Sex workers have the right
to benefit from health-
related scientific progress
9. Sex workers have the right
to access the basic
necessities (housing, food,
and clothing) for an
adequate standard of living.

d) Willingness to treat sex workers

Item Strongly Disagree Neutral Agree Strongly

disagree agree
1 2 3 4 5
1. If I am allowed to choose,
I will not choose to
provide care to patients
who are sex workers
2. I would refuse to care for
patients who are sex
workers
3. I am willing to take care
of patients who are sex
workers

Part IV Education needs

1. How do you think the topic of sex workers should be addressed in the
undergraduate nursing curriculum?
a. It should be addressed in the undergraduate nursing curriculum
b. Training would be needed only for those who work in units that have frequent
encounters with sex workers
c. It should be addressed in the Office of General University Requirement
(OGUR).
d. There is little need for formal training, such topic can be leaned through self-
learning or service-learning activities.
e. There is no need at all to address the topic of sex workers in the undergraduate
nursing curriculum

411
 f. I have no idea
g. Others
2. Which education approach do you prefer to acquire knowledge related to
caring for sex workers? (You can select more than one option)
a. Lecture
b. Workshop/seminar
c. Service-learning
d. Self-learning
e. Volunteer training organized by NGOs
f. I have no interest in such topic
g. Others

412
Appendix XV
Formulae for calculating effect size for RCT
and quasi-experimental study with controlled group

a. Formulae for calculating d for RCT:

ES (Cohen‘s d) = [MeanT – MeanC]/ SDpooled

SDpooled = √[SDT2 +SDC2]/2

b. Formulae for calculating d for controlled trials:

ESPre-/Post-Test Two Groups (Cohen‘s d) = c[(MeanTpost – MeanTpre) – (MeanCpost –

MCpre)]/SDpooled

SDpooled = √[(nT – 1)SDTpre2 + (nC – 1)SDCpre2]/(nT + nC – 2)

c = 1 – 3/(4(nT + nC – 2) – 1)

MeanTpre, = mean of treatment group at pre-intervention

MeanTpost = mean of treatment group at post-intervention

MeanCpre, = mean of control group at pre-intervention

MCpost = mean of control group at post-intervention

SDpooled = pooled standard deviation at pre-intervention;

SDTpre, SDCpre = standard deviation at pre-intervention of treatment and control group,

respectively;

nT = sample size of treatment;

nC = sample size of control group

413
c = bias correction factor

414
Appendix XVI Certificate of volunteer training

415
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