Community collectivization and its association with consistent condom use and STI treatment-seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India

Figures & data

Table 1. Definition and coding of community mobilization indicators used in Behavioral Tracking Survey (2010–2011).

Community mobilization indicator	Definition and coding
Collective efficacy (both FSWs and HR-MSM)	Collective efficacy is the belief of the affected community in its power to work together to bring positive changes. It was measured based on responses to the question: How confident are you that FSWs in your community can work together to achieve the following goals: keep each other safe from harm; increase condom use with clients; speak up for your rights; and improve your lives? Responses to these questions included: not at all, somewhat, very, and completely confident. A composite index was constructed. The scale had reliability (Cronbach's alpha) of 0.831 for FSWs and 0.928 for HR-MSM. The index score was further divided into two equal categories of collective efficacy: low (1–2.4999) and high (2.5–4).
Collective agency (only for FSWs)	Collective agency is the choice, control, and powers that poor or marginalized groups have to act for themselves to claim their rights (whether civil, political, economic, social or cultural) and to hold others accountable for these rights. It was measured based on responses to the question: In the past 6 months, have you negotiated with or stood up against the following stakeholders (police, madam/broker, local goon [gang member], clients or any other sexual partner) in order to help a fellow sex worker or to help fellow sex workers? A separate question for each of the above stakeholders was asked, with the possible binary response categories “Yes” (coded as 1) and “No” (coded as 0). Using these four questions and corresponding responses, an index was constructed, with the scale values ranging from 0–1, which had reliability (Cronbach's alpha) of 0.782. The index score was further divided into two equal categories of collective agency: low (0–0.4999) and high (0.5–1).
Collective action (only for FSWs)	Collective action is the strategic and organized activities by mobilized community members to increase the community's visibility in wider society and present or enact its agenda for change (for example, through rallies, demonstrations, or meetings with stakeholders). It was measured based on responses to the following seven questions: Whether the sex workers group come together to demand/help for the following: (1) ration card, (2) voter card, (3) bank account, (4) free education for children, (5) health insurance, (6) representation in government forums, (7) better health services from the government. A separate question was asked for each of the above social entitlements and services with the possible binary response categories “Yes” (coded as 1) and “No” (coded as 0). Using these seven questions and corresponding responses, an index was constructed, with the scale values ranging from 0 to 1, which had reliability (Cronbach's alpha) of 0.782. The index score was further divided into two equal categories of collective action: low (0–0.4999) and high (0.5–1).
Participation in public events (only for HR-MSM)	Participation in public events was measured as whether the respondents participated in any public event in the past six months at risk of being identified as HR-MSM (no, yes). It was derived based on single questions in the questionnaire.

Notes: FSWs: Female sex workers; HR-MSM: High-risk men who have sex with men/transgenders.

Table 2. Measurement of outcome indicators and mediators used in Behavioral Tracking Survey (2010–2011).

	Definitions and coding
Outcome indicators
CCU with occasional clients and regular clients (only for FSWs)	CCU with a given type of clients (occasional, regular) was defined as use of condom in every sexual encounter with that type of client. Occasional clients were defined as men whom FSWs did not knew or do not recognize their faces. Regular clients were defined as men whom FSWs knew well and could recognized their faces.
CCU with paid partners and paying partners (only for HR-MSM)	CCU with a given type of partner (paid, paying) was defined as use of condom in every sexual encounter with that type of partner. Paid partners were defined as men/transgenders whom the respondent paid for sex. Paying partners were defined as men/transgenders who paid the respondent for sex.
STI treatment from government health facilities	The STI treatment-seeking from government health facilities in the past one year was defined as whether or not an individual visited government health facilities for treatment of any STI, irrespective of his/her seeking treatment for STIs at other places. Among FSWs, any STI was defined as presence of any of the following two symptoms in the past one year: (1) genital sore/ulcer; (2) yellowish/greenish discharge from vagina. Among HR-MSM, any STI was defined as presence of any of the following three symptoms in past one year: (1) genital sore/ulcer; (2) anal sore/ulcer; and (3) unusual discharge from penis/anus.
Potential mediators
Self-efficacy for condom use with commercial partners	Self-efficacy for condom use with commercial partners refers to the ability of FSWs/HR-MSM to negotiate for condom use with their commercial partners. It was measured by three questions assessing self-efficacy for each time condom use with commercial partners: How confident are you that you can use a condom with each commercial partner when (1) he gets angry with you; (2) he offers you more money for sex without a condom; or (3) you have been using alcohol or drugs? Responses to these questions included: not at all (coded as 1), somewhat (coded as 2), very (coded as 3), and completely confident (coded as 4). Using these four questions and corresponding responses, an index was constructed, with the scale value ranging from 1 to 4, which had reliability (Cronbach's alpha) of 0.850 for FSWs and 0.898 for HR-MSM. The index score was further divided into two equal categories of self-efficacy for condom use with clients: low (1–2.4999) and high (2.5–4).
Self-efficacy for service utilization from government health facilities	Self-efficacy for service utilization from government health facilities among FSWs/ HR-MSM was measured based on responses to the following two questions: (1) How confident are you that you can go to the government health clinic to get reproductive health services you need if the health workers there treat you badly; and (b) How confident are you that you can go to the government health clinic to get the reproductive health services even if the health worker knows that you are a FSW/MSM? Responses to these questions included: not at all (coded as 1), somewhat (coded as 2), very (coded as 3), and completely confident (coded as 4). Using responses to the two questions an index was constructed with the scale values ranging from 1 to 4 which had reliability (Cronbach's alpha) of 0.869 for FSWs and 0.927 for HR-MSM. The index score was further divided into two equal categories of self-efficacy for service utilization: low (1–2.4999) and high (2.5–4).

Notes: FSWs, female sex workers; HR-MSM, high-risk men who have sex with men/transgenders; STI, sexually transmitted infection; CCU, consistent condom use

Table 3. Demographics, community mobilization indicators, direct and indirect outcome indicators among FSWs (N=3557) and HR-MSM (N=2399), Andhra Pradesh, India.

	FSWs		HR-MSM
Background characteristics	N	Percentage or Mean (SD)	N	Percentage or Mean (SD)
Sociodemographic
Age ≥ 30 years	1679	47.2	763	31.8
Average age (years)		29.4 (5.7)		27.6 (6.1)
Formal schooling^a	1510	42.4	1780	74.2
Currently married	2154	60.6	779	32.5
Formerly married^b	1125	31.6	89	3.7
No source of income other than sex work	773	21.7	302	12.6
Currently in debt	2844	79.9	976	40.7
Mobility for sex work
Visited places and had sex in past two years	1410	39.6	1852	77.2
Visited places outside district and had sex in past two years	996	28.0	1428	59.5
Duration of practicing sex work (for FSWs)/anal sex with man/transgenders (for MSM) (in years)
< 2	243	6.8	60	2.5
2–4	1645	46.2	464	19.3
5–9	1332	37.5	851	35.5
10 or more	337	9.5	1024	42.7
Average duration		4.8 (3.3)		9.2 (5.9)
Place of solicitation for sex work
Home	1124	31.6
Public places (streets, highways, and parks)	2233	62.8
Brothels or lodges	200	5.6
Community mobilization indicators
Collective efficacy: high	2815	79.1	1489	62.1
Collective agency: high	1339	37.7
Collective action: high	663	18.6
Participation in public event in past six months			1916	79.9
Outcome indicators
CCU with occasional clients	2691	75.7
CCU with regular clients^c (N=3521)	2380	67.6
CCU with paid partners^d (N=620)			433	69.8
CCU with paying partners^e (N=1679)			1213	72.2
STI treatment from government health facilities in past one year^f (FSWs: N=1521; HR-MSM: N=320)	873	57.4	132	41.3
Potential mediators
Self efficacy for condom use with clients: high	2481	69.7	1731	72.2
Self efficacy for service utilization from government health facilities: high	1978	55.6	1323	55.2

Notes: Average refers to the mean values.

FSWs, female sex workers; HR-MSM, high-risk men who have sex with men/transgenders; STI, sexually transmitted infection; CCU, consistent condom use; SD, standard deviation.

^a Formal schooling refers to the ability to both read and write.

^b Formerly married refers to those who were divorced, separated, or widowed.

^c Among FSWs who reported having regular clients in past one year.

^d Among HR-MSM who reported having paid partners (partners whom respondents paid for sex) in past one year.

^e Among HR-MSM who reported having paying partners (partners who paid respondents for sex) in past one year.

^f Among those FSWs and HR-MSM who reported having any STI in past one year. Among FSWs, any STI was defined as presence of any of the following two symptoms in the past one year: (1) genital sore/ulcer; (2) yellowish/greenish discharge from vagina. Among HR-MSM, any STI was defined as presence of any of the following three symptoms in past one year: (1) genital sore/ulcer; (2) anal sore/ulcer; and (3) unusual discharge from penis/anus.

Table 4. Relationship of collectivization with outcome indicators and mediators among female sex workers in Andhra Pradesh (Behavioral Tracking Survey 2010–2011).

	Collective efficacy		Collective agency		Collective action
Outcome indicators and potential mediators	Low	High	Low	High	Low	High
Outcome indicators
Consistent condom use with occasional clients (%)	71.6	76.7	76.8	73.8	74.8	79.5
Adjusted OR (95% CI)	Referent	1.3 (1.1–1.7)	Referent	0.9 (0.7–1.1)	Referent	1.3 (1.1–1.8)
Consistent condom use with regular clients (%)	61.9	69.1	69.4	64.7	66.2	73.6
Adjusted OR (95% CI)	Referent	1.4 (1.1–1.9)	Referent	0.8 (0.6–1.1)	Referent	1.5 (1.1–2.0)
STI treatment from government health facilities in past one year (%)	32.1	59.8	49.9	61.9	59.1	44.3
Adjusted OR (95% CI)	Referent	3.3 (2.1–5.1)	Referent	1.6 (1.1–2.2)	Referent	0.5 (0.3–0.8)
Potential mediators
High self-efficacy for condom use with clients (%)	63.5	71.4	72.0	66.0	68.4	75.7
Adjusted OR (95% CI)	Referent	1.5 (1.1–2.0)	Referent	0.7 (0.5–0.9)	Referent	1.6(1.1–2.2)
High self-efficacy for service utilization from government health facilities (%)	37.3	60.5	48.3	67.7	51.9	72.1
Adjusted OR (95% CI)	Referent	2.6 (2.1–3.2)	Referent	2.1 (1.7–2.6)	Referent	2.4 (1.7–3.5)

Notes: Odds ratios were adjusted for current age (entered as continuous variable); formal schooling (yes, no); marital status (currently married, not currently married); source of income other than sex work (yes, no); place of solicitation for sex work (home, public places, brothel/lodges); visited any place for sex work in past two years (yes, no); duration of sex work in years (entered as continuous variable).

OR, odds ratios; CI, confidence intervals; STI, sexually transmitted infection.

Table 5. Relationship of collectivization with outcome indicators and mediators among men who have sex with men/transgenders in Andhra Pradesh (Behavioral Tracking Survey, 2010–2011).

	Participation in public event		Collective efficacy
Outcome indicators and potential mediators	No	Yes	Low	High
Outcome indicators
Consistent condom use with paid partners (%)	48.1	74.3	67.9	71.4
Adjusted OR (95% CI)	Referent	3.3 (2.1–5.2)	Referent	1.3 (0.8–1.7)
Consistent condom use with paying partners (%)	54.9	75.3	64.0	76.5
Adjusted OR (95% CI)	Referent	2.7 (2.0–3.6)	Referent	1.9 (1.5–2.3)
STI treatment from government health facilities in past one year (%)	44.9	40.9	42.9	40.5
Adjusted OR (95% CI)	Referent	0.9 (0.4–2.0)	Referent	1.0 (0.6–1.7)
Potential mediators
High self-efficacy for condom use with clients (%)	63.7	74.4	51.6	84.7
Adjusted OR (95% CI)	Referent	1.8 (1.4–2.2)	Referent	4.9 (4.1–6.0)
High self-efficacy for service utilization from government health facilities (%)	38.0	59.5	35.9	66.9
Adjusted OR (95% CI)	Referent	2.5 (2.0–3.1)	Referent	3.6 (3.0–4.3)

Notes: Odds ratios were adjusted for current age (entered as continuous variable), formal schooling (yes, no), marital status (currently married, not currently married), sex work is main source of income (yes, no), had sex with men/ transgenders while visiting any place in past two years (yes, no), duration since first anal sex (entered as continuous variable).

OR, odds ratios; CI, confidence intervals; STI, sexually transmitted infection.

Table 6. Effects of collectivization and mediators on outcome indicators among female sex workers, and high-risk men who have sex with men/transgendres in Andhra Pradesh (Behavioral Tracking Survey 2010–2011).

	FSWs
	Consistent condom use with occasional clients		Consistent condom use with regular clients		STI treatment from government health facilities in past one year^a
Collectivization indicators and corresponding mediators	Adjusted OR for collectivization^b (95% CI)	Adjusted OR for mediator^c (95% CI)	Adjusted OR for collectivization^b (95% CI)	Adjusted OR for mediator^c (95% CI)	Adjusted OR for collectivization^b (95% CI)	Adjusted OR for mediator^c (95% CI)
Collective efficacy and corresponding mediators
Self-efficacy for condom use with commercial partners	1.1 (0.8–1.5)	2.5 (2.0–3.1)	1.3 (1.1–1.7)	2.3 (1.9–2.8)	–	–
Self-efficacy for service utilization from government health facilities	–	–	–	–	3.6 (2.3–5.6)	0.9 (0.5–1.2)
Collective agency and corresponding mediators
Self-efficacy for service utilization from government health facilities	–	–	–	–	1.6 (1.2–2.3)	0.7 (0.6–1.0)
Collective action and corresponding mediators
Self-efficacy for condom use with commercial partners	1.2 (0.9–1.7)	2.7 (2.1–3.5)	1.4 (1.1–1.9)	2.3 (1.9–2.8)	–	–
Self-efficacy for service utilization from government health facilities	–	–	–	–	0.6 (0.4–0.8)	0.8 (0.6–1.1)
	HR-MSM
	Consistent condom use with paid partners			Consistent condom use with paying partners
Collectivization indicators and corresponding mediators	Adjusted OR for collectivization^b (95% CI)		Adjusted OR for mediator^c (95% CI)	Adjusted OR for collectivization^b (95% CI)	Adjusted OR for mediator^c (95% CI)
Participation in public event and corresponding mediators
Self-efficacy for condom use with commercial partners	1.9 (1.3–2.9)		2.9 (1.8–4.5)	2.6 (2.0–3.5)	1.6 (1.3–2.1)
Collective efficacy and corresponding mediators
Self-efficacy for condom use with commercial partners	–		–	1.7 (1.3–2.2)	1.3 (1.1–1.7)

OR, odds ratios; CI, confidence intervals; STI, sexually transmitted infection; FSWs, female sex workers; HR-MSM, High-risk men who have sex with men/transgenders.

^a Analysis was restricted to those who reported to have suffered from any STI in past one year.

^b Odds ratios were adjusted for the corresponding mediators along with the sociodemographic characteristics: current age (entered as continuous variable), formal schooling (yes, no), marital status (currently married, not currently married), sex work is main source of income (yes, no), had sex with men/transgenders while visiting any place in past two years (yes, no), duration since first anal sex (entered as continuous variable).

^c Odds ratios were adjusted for the corresponding collectivization indicator along with the socio-demographic characteristics: current age (entered as continuous variable), formal schooling (yes, no), marital status (currently married, not currently married), sex work is main source of income (yes, no), had sex with men/transgenders while visiting any place in past two years (yes, no), duration since first anal sex (entered as continuous variable).