30 October 2011: We discussed Ghimire et al (2011) ‘Reasons for non-use of condoms and self-efficacy among female sex workers: a qualitative study in Nepal’, BMC Women’s Health 11: 42. There is a link to the full transcript of the chat in the Archive.
This paper reports part of a wider study on female sex workers in Nepal. Other parts of the study that were mentioned in the paper included a questionnaire with 425 respondents, and field observations. This paper focuses on in-depth interviews with 15 women.
I summed up the overall appraisal of the paper thus:
There were interesting data and observations, and the study itself was probably valuable. However, the paper has a number of shortcomings, which are discussed below.
1. It was felt that the concept of ‘self-efficacy’ (SE), signposted in the title, was ‘shoehorned’ in. We questioned its relevance for a qualitative study. It was problematic that this concept was not defined at all in the body of the paper, nor was it discussed in the literature review section. This made it difficult to judge the validity of its use as an explanatory concept in the analysis.
The ‘fundamental attribution error’ is where the behaviour of others is attributed to personality based factors; while an analysis of one’s own behaviour might recognise the importance of situational and contextual factors (Wikipedia entry). This seems particularly pertinent in relation to this paper. The findings that were most interesting to the readers in the journal club were the ‘structural’ factors that militated against the women’s use of condoms. These included:
- intimidation by law enforcement officers – invited or exacerbated where women were found to be carrying condoms
- the women’s socio-economic position made them relatively powerless in the transactional relationship (felt unable to refuse client if they declined to use a condom, as they needed the money)
- male clients’ frequent refusal to use condoms.
2. Recruitment, data collection process and ethical issues were inadquately discussed. The interview participants had been purposively sampled from the 425 questionnaire respondents. The criteria for selecting possible participants; and the method of approach, were not clarified, although it ws mentioned that the researchers sought women across the chosen age range (15-45) and of varied marital and socio-economic statuses. Discussion of ethical issues was somewhat mechanistic, given the very sensitive nature of the topic (and the secrecy under which many of the women were obliged to pursue commerical sex work). Interviews were usually conducted in a ‘public’ place so as to preserve confidentiality. Given what is revealed in the findings – that many of the women’s husbands and partners were not aware that they engaged in sex work, it seems logical not to hold interviews in the women’s own homes. However, the nature of the ‘public’ locations is not detailed. It appears odd to use a public location for a very lengthy (up to five hours) interview in order to maintain confidentiality. Some of the women revealed violence and intimidation; it was not clear whether they were directed towards help, which would normally be an ethical responsibility for the researcher.
3. Conclusions not clearly leading on from findings. This is from the Conclusion section:
This study considers that sex workers were highly vulnerable due to low Self-Efficacy (SE) for their health compromising behaviours, anxiety, fear of life threatened disease like HIV, poor physical, mental and social health, lower levels of education and livelihood problems. Poverty, gender inequality, lack of empowerment [45,46] and low social status diminishes an individual’s ability to act on positive intentions to use condoms with clients.
Not all of these factors in vulnerability had been properly discussed or demonstrated in the paper – particularly ‘low Self-Efficacy’ and ‘poor physical, mental and social health’. It may be that these were clear findings that emerged from the other stages of the study (e.g. the questionnaire) – however, this is not specified.
The following part of the conclusion is more in line with the findings that are detailed in the paper:
Economic empowerment of women and other structural interventions may provide a more sustainable means of STI and HIV prevention by strengthening the ability of communities to help individuals to reduce these risks and vulnerabilities.
It is therefore disappointing that the final words of the article make the following recommendations:
implementation of FSW empowerment and behaviour, targeted education, information and communication programmes along with improved provision of health services for the FSWs would reinforce the relevant policy changes will also uplift the SE of FSWs.
All of the participants reported being well aware about the risk reduction potential of using condoms. One of the most interesting findings was that some of the research participants were themselves designated ‘peer educators’, who still did not routinely use condoms:
It seemed that a focus on clients in terms of education and awareness could have some benefits. This was clear because some of the women reported that ‘foreign’ clients usually insisted on using condoms; whereas Nepali men often refused. It is recognised that HIV prevention strategies focused upon sex work have been inadequate in their engagement of clients (see e.g. UNAIDS 2011).
Overall we felt that some very interesting findings from an extensive field-based study were poorly presented and framed in this paper.