HIV risk and psychological distress among female entertainment workers in Cambodia: a cross-sectional study

Brody et al. BMC Public Health (2016) 16:133 DOI 10.1186/s12889-016-2814-6 RESEARCH ARTICLE Open Access HIV risk and psychological distress among female entertainment workers in Cambodia: a cross-sectional study Carinne Brody1, Pheak Chhoun2, Sovannary Tuot2, Khuondyla Pal2, Kolab Chhim2 and Siyan Yi1,2* Abstract Background: In Cambodia, there has been an increase in entertainment work as a result of the breakdown of the traditional brothel-based sex industry, presenting new challenges to addressing the health issues and needs of people working in the entertainment industry. This study aims to identify factors associated with psychological distress among female entertainment workers (FEWs) in Cambodia. Methods: A two-stage cluster sampling method was used to randomly select 657 FEWs from entertainment establishments in Phnom Penh and Siem Reap in April and May 2014 for interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12), and multivariate logistic regression analysis was conducted. Results: Almost half of FEWs (43.2 %) had a higher level of psychological distress (GHQ-12 > 3), while 19.5 % reported having suicidal thoughts, and 7.3 % reported having attempted to commit suicide in the past 3 months. Controlling for confounding factors, women with a higher level of psychological distress were significantly more likely to rate their overall health (AOR = 1.88, 95 % CI 1.20 to 2.94) and quality of life (AOR = 2.39, 95 % CI 1.47 to 3.87) as poor. They were also significantly more likely to have suicidal ideation (AOR = 2.41, 95 % CI 1.45 to 3.76), rate their HIV risk as higher than the general population (AOR = 0.48, 95 % CI 0.31 to 0.74), have been forced to drink at work (AOR = 1.77, 95 % CI 1.19 to 2.62), have had clients requesting not to use a condom (AOR = 3.48, 95 % CI 1.14 to 10.62), be not able to find condoms when they needed it (AOR = 0.64, 95 % CI 0.45 to 0.93), have had a family member who said hurtful things to them during childhood (AOR = 1.84, 95 % CI 1.24 to 2.75), and have had a parent or guardian who had been physically abused (AOR = 1.93, 95 % CI 1.34 to 2.82). Conclusions: FEWs in Cambodia experience high levels of psychological distress, which likely stems from both past negative experiences and current working conditions. For women that are experiencing psychological distress, intervention programs aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk. Keywords: Female entertainment workers, Sex work, Psychological distress, Mental health, HIV, Cambodia * Correspondence: 1 Center for Global Health Research, Public Health Program, Touro University California, 1310 Club Drive, Vallejo, CA 94592, USA 2 Center for Population Health Research, KHANA, No. 33, Street 71, Tonle Bassac, Chamkar Morn, P.O. Box 2311-PP3, Phnom Penh, Cambodia © 2016 Brody et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Brody et al. BMC Public Health (2016) 16:133 Background Female entertainment workers (FEWs) are typically young women in developing countries, particularly in Asia, who work at establishments such as karaoke bars, restaurants, beer gardens or massage parlors. Entertainment work is often associated with sex work [1, 2], where women employed as singers, beer promoters, or masseuses sell sex to male patrons to supplement their income. FEWs, in particular those who participate in sex work, are at greater risk for health problems than the general women population due to occupational hazards such as engaging in unsafe sex, exposure to violence, and drug use [1–3]. This group can be difficult to reach with health services due to the hidden and stigmatizing nature of their work [2, 3]. Despite these occupational stressors, mental health of female sex workers (FSWs) is understudied [4]. The most relevant data on the mental health of this population come from studies assessing the mental health of FSWs. Available evidence suggests that FSWs experience worse mental health outcomes than the general public such as high rates of anxiety, depression, posttraumatic stress disorder (PTSD), and psychological distress [4–7]. These poor mental health outcomes have been associated with experiences of violence, childhood trauma, drug addiction, and the experience of stigma as reported in a review of the literature [8]. The existing evidence does not establish a temporal relationship but suggests that there is likely a bi-directional relationship between poor mental health and sex work. Studies suggest that poor mental health among FSWs can lead to more health risk behaviors such as substance use or unsafe sex. In China and Iran, studies have shown that FSWs with severe depressive symptoms were less likely to use condoms consistently [9, 10]; and in the United States and Puerto Rico, FSWs exhibiting depressive symptoms were more likely to engage in unsafe drug use practices such as needle sharing [11–13]. These studies suggest that FSWs experiencing poor mental health are at greater risk of contracting HIV. In Cambodia, the patterns of entertainment work have changed dramatically, which complicates the provision of any type of health services. The global financial crisis of 2007–08, which lead to high unemployment in the garment sector, and the 2008 ‘Law on Suppression of Human Trafficking and Sexual Exploitation’ that banned brothel-based sex work [14] have created a large influx of young women working in the entertainment and informal sex industry. Today, more young women than ever are working in karaoke parlors, restaurants, beer gardens, massage parlors, bars, or nightclubs. At these establishments, some women engage in sexual relationships in exchange for money, gifts, or other benefits for themselves or their family [15]. Page 2 of 10 Many FEWs in Cambodia come from low-income rural households, have low education levels, and have received only limited health education [14]. As urban migrants, these women face a changing social context and increased stigma with less social support [16, 17]. These factors may result in an increasing vulnerability to mental health problems for this population. The breakdown of the traditional brothel-based sex industry and the emergence of indirect methods of selling sex through entertainment venues have created challenges to identifying FEWs and pr (...truncated)