Female Sex Workers Programme Impact Assessment

This 25-page report shares finding of an impact assessment of Theatre For Change's "Interactive Theatre and Legislative theatre for sex workers and their clients" project in Malawi. The initiative was designed to ensure that sex workers, their clients, and sexually exploited children have the knowledge, attitudes, and skills to reduce the risk of HIV transmission and report implementing them consistently in their lives. It also worked to ensure that sex workers and sexually exploited children are able to advocate for their right to live in safer environments, free from gender-based violence, and that they have the personal and professional skills to generate a liveable income or return to school. According to the report, overall, the results suggest that women improved understanding and knowledge in most areas including around condom use, gender rights, and self-confidence/efficacy, although it was disappointing to see comprehensive knowledge of HIV drop amongst the group.

As stated in the report, the majority (77%) of female sex workers who took part in the programme were aged between 19 and 30, with 16% below 18 years old and 8% between 31 and 40. During the recruitment of participants into the programme, organisers made a distinction between sex workers who are over 18 years of age and sexually exploited children who are under 18. They then ran two separate behaviour change programmes designed to meet the needs of these two distinct groups.

At the start of the programme, sex work was reported as the main source of income for the majority of participants (92%). The amount of money made on a typical day/night was around 2,800MKW (£5.60). With the average GNI per capita in Malawi recorded as $320 per year/$0.87 per day (World Bank: 2012) it is easy to see why women are reluctant to leave sex work, which is a fairly lucrative business compared to other forms of income. However, the number of women reporting involvement in sex work did drop 13.5% over the lifetime of the programme, with 79% of women reporting sex work as their main source of income in the endline, compared to 92% at the start. Along with a drop in the number of women who stated that sex work was their primary source of income, there was also a drop in the number of days that women were engaging in sex work at the start and end of the programme. At the baseline, 70% reported working every day, with 48% reporting the same in the endline.

Women improved knowledge in all but two of the areas surveyed, with a drop of 33% in the number of women who believed that a healthy looking person could have HIV and no change in the number who knew you could not get HIV from a mosquito bite. Because of the results in these two areas, the number of individual women who could demonstrate a "comprehensive" knowledge of HIV was skewed and dropped from 81% to 79% between the start and end of the programme. Participants were asked 15 questions relating to male and female condoms. There were gains in 14 of the 15 areas, with no change in the already high percentage (92%) of women agreeing that "it's OK for a man to ask a woman to use a female condom". The largest change (39%) came in the number of women reporting that they know how to use a female condom. However, the reported number did not align to the number of women actually able to demonstrate correct female condom use in real life.

There are eight necessary steps for demonstrating correct male condom use, including checking the expiration date and pushing air out of the tip before rolling it down the penis in the correct way round. In the baseline, none of the 69 women observed were able to effectively demonstrate how to use a male or female condom. Just 4% of women were able to demonstrate male condom use with one "missing" step. At the end of the programme, 46% of women were able to demonstrate correct use of a male condom, completing all of the eight necessary steps. A further 13% of the women were able to demonstrate seven of the eight steps. The 59% difference was a huge improvement, which shows there is a need to continue to hold condom demonstration sessions to ensure all women have a chance to practice and perfect the steps needed to properly use a condom.

According to the report, women found negotiating condom use with husbands and partners much more difficult than with clients. In focus group discussions with female sex workers in Area 25, women described the information they had learned about using condoms with clients and the confidence they now had in negotiating their use. However, when probed about whether the same applied to their personal relationships, the women said it was sometimes hard to explain to a loved one about the importance of condom use as it is seen as undermining trust. One participant in Kawale said "when you have a condom some men say that that means you are too much of a sex worker and they leave you".

The report offers the following recommendations for strengthening the impact of the initiative:

• Age of participants: During the analysis of survey results, researchers found that 8 participants responded that they were less than 18 years of age, despite researchers clearly discussing with participants that they should be above 18 years old to take part in the programme. When recruiting participants in the future, it is recommended that TfaC staff members are explicit in communicating the fact that there are two separate programmes for sex workers over 18 and those under 18, which they define as sexually exploited children.
• HIV knowledge: There is a clear need to spend more time communicating key messages about how HIV is transmitted - in particular, focusing on common local misconceptions, which are often based on deeply held beliefs and take time to shift. Understanding that a healthy looking person can have HIV is also an area that needs to be discussed clearly with the groups, as there was a negative change in this indicator over the life of the programme.
• Stigma and discrimination: The majority of women interviewed reported that they faced high levels of stigma and discrimination within their communities. For the women to be accepted as part of the community, there is a need to address local opinion of sex workers in a more consolidated way. One mechanism for doing this would be through the Nzotheka radio programme, which they are hoping to continue. Another way of spreading positive messages about sex workers in communities could be through the work of the Sex Workers Network.
• Collecting data: There were a few areas of the survey where information given by women seemed to change unexpectedly over the course of the programme, particularly in relation to demographics. In future, it would be worth thinking of practical ways to extract more reliable answers from participants, possibly through face-to-face interviewing or by using alternative means for assessing knowledge, such as a series of pictures that women have to identify to prove understanding.
• Observations of behaviour: TfaC staff have noted that, although observations of women's reaction to a "real life" situation gives a better idea of self-efficacy and confidence, by the endline, the women have often met the staff member playing the role of the policeman in the observed role play. This is likely to mean that women display higher levels of confidence than if they faced the same situation in real life. However, observing behaviour still gives a good idea of where women are able to assert themselves by using their body, voice, and space.
• Focus group discussions: Focus group discussions were held with groups of women before the programme started, but these acted more as a "needs assessment" than to enrich the survey and observation data. Focus groups held at the end of the programme were hard to convene and explored general programme areas rather than specific questions relating to findings in the baseline and endline surveys. Focusing on specific areas might help explain "negative" changes in areas like stigma and discrimination and follow-up of reports of abuse by the police, as the women might explain that it was easier to report their experiences honestly after taking part in the programme.
• Condom use: The positive change in the number of women able to use male and female condoms represents one of the achievements of the programme. However, there are still gains to be made with the remainder of the women who are unable to demonstrate how to correctly use a condom. It is recommended that practical condom demonstrations be held on a regular basis with TfaC participants, even if this means they are repeatedly exposed to the same activity. Developing the ability to correctly use a condom takes some time.