Condom Attitudes of Female
Entertainment Workers in Metro Manila,
the Philippines: Setting, Peer Influence
and Social Support
Lianne A. Urada, PhD, MSW, LCSW 1
Steffanie A. Strathdee, PhD 1
Robert F. Schilling, PhD 2
Benilda de Guia 3
Donald E. Morisky, Sc.D., Sc.M., M.S.P.H. 4
University of California at San Diego, Division of Global Public Health, Department of
Medicine 2 University of California at Los Angeles, Department of Social Welfare 3
PAMAC-Q (Peer Educator's Movement for Empowerment), Philippines 4 University of
California at Los Angeles, Department of Community Health Sciences
1
Funded by: T32 DA023356, UC Pacific Rim Research Program, UCLA International Institute
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
HIV in the Philippines
1 of 7 countries with a
≥ 25% increase in new cases
in 2011 (UNAIDS, 2011).
HIV increased 3-fold among
Female Sex Workers
(2007 to 2010).
Quezon City = largest suburb
of Metro Manila (48% of HIV
cases)
Sex Work in the Philippines
...is not legalized. However,
Quezon City
Requirements for
Female Bar/Spa
Workers:
 Health certificates
 HIV/AIDS seminars
 Weekly STI exams
Objective/Hypotheses
 To assess individual, social, and physical
risk environment factors associated with
condom attitudes among female bar/spa
workers in Quezon City, Metro Manila.
Hypotheses:
More positive condom attitudes are associated
with:
1) Peer and manager support for condom use
2) Social support
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Methods
Sampling, Recruitment
 Bar/night club, spa/sauna, karaoke bars
stratified by size and type.
 Modified time-location sampling of individuals
at venue/clinic: all interviewed (smaller venues
with ≤10 workers) or else randomly sampled.
Data collection: Interviews
 Trained local NGO peer educators as
interviewers.
 Interviewer-administered surveys with female
bar/ spa workers (N=498) from 54 venues in
Quezon City, Metro Manila (2009-2010).
Measures
Definition
Condom Attitudes Scale*
 10-items (1-strongly agree, 5-strongly disagree)
Max. possible score: 50
Drug use
 How often do you take drugs
(0-never , 5-always)
General Social Support
 Emotional, Tangible, Functional
(0-not at all, 4-great deal) Max. possible score: 196
(Norbeck, 1984)
Manager Support for
condom use*
 (condom use with venue guests)
(Yes/No)
Peer Support for condom
use (Co-worker)*
(Yes/No)
 Ever discussed STI/HIV prevention
 Ever tried to convince worker to use
condoms with venue guests
 Used condom when having sex with venue
patron due to co-worker’s advice
Venue Policy*
(Yes/No)
*Adapted from Morisky et al (2002)
 Condom use rule
 Condom availability for workers
Statistical Analysis
 Data analysis restricted to those having sex
past 6 months (N= 356).
 Hierarchical Linear Regression, adjusted for
age, education, and individuals nested within
venues.
 Tested for plausible 2-way interactions.
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Results: Socio-Behavioral Demographics, N=356*
Characteristic
%, Median/IQR
Individual
Age (median years/IQR)
22 (20-26)
Education (years) (H.S. diploma=10th grade)
10 (9-11)
Months worked as bar/spa worker
14 (8-32)
Drug use (current) (e.g. Methamphetamines)
10
Alcohol use (daily)
15
Consistent condom use
45
Knowledge of AIDS (1-none to 5-great deal)
2 (2-4)
Social Risk Environment
Peer support (co-workers) for condom use
Manager support for condom use
General social support (not for HIV/STI prevention)
1 (0-3)
25
79 (53-101)
Physical Risk Environment
Venue type - Night club/bar
Spa/sauna
Karaoke bar
35
49
16
Condom rule at venue
29
Condom availability at venue
32
Condom Attitudes (N=356)
Condom price is too high
Goes against religion
Men lose erection
Causes pain or discomfort
Agree
Use depends on men in my culture
Neutral
Will use if sex partner asks
Disagree
Lowers HIV during vaginal sex
Lowers HIV during anal sex
Prevents STIs
Prevents pregnancy
0
10
20
30
40
50
%
60
70
80
90
Factors Significantly Associated with More Positive Condom
Attitudes, Female Bar/Spa Workers in the Philippines (N= 356)
Model 1
Beta
95%
Confidence
Intervals
Model 2
Beta
95%
Confidence
Intervals
Individual
Drug use (inverse association)
- 1.13 - 1.78, - 0.48
-1.14
- 1.76, - 0.52
- 0.03, 2.56
Physical Risk Environment
Work in spa/saunas
vs. night club/bars
1.36
0.06, 2.67
1.26
0.31
0.01, 0.63
--
Social Risk Environment
Peer support (co-workers) for
condom use
--
Manager support for condom use
--
--
0.29
- 0.74, 1.33
General social support
--
--
0.01
- 0.01, 0.01
(Interaction) General social
support x Manager support for
condoms
--
--
0.03
0.01, 0.05
*Hierarchical Linear Regression, adjusted for individuals nested within venues, age, education
31
32
33
34
35
36
Model 2. Predicted Condom Attitudes
for the Average Female Bar/Spa Worker
-100
-50
0
general social support
no manager support-condom
Note: Data were centered by subtracting the mean value
50
100
manager supports condom
Limitations
 Self-reported data
 Cross-sectional design
 Potential recall bias for measures without
specific time frames
 Generalizability limited to venues/individuals
who agreed to participate in Quezon City
(20% refused)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Conclusions
Individual
 Drug use was negatively associated with condom
attitudes & needs further exploration for female bar/
spa workers.
Physical Risk Environment
 Night club/bar workers had poorer condom attitudes
than spa workers, suggesting additional intervention
is needed.
Social Risk Environment
 Buy-in from co-workers of condom use is critical.
 Efforts needed to increase social support for sex
workers and manager support for condom use.
Implications- Next Steps
• Social support must be bolstered (e.g.
collective action/ community mobilization)
• Remove macro-level structural barriers to
condom use (e.g., religious opposition,
funding)
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
Acknowledgements
Salamat po!
Philippines Team:
 Benilda de Guia, Jay Caparida, & Junelyn Tabelin, Philippine Rural
Reconstruction Movement, Inc., & PAMACQ (Peer Educator's Movement for
Empowerment Pasay, Manila, Caloocan & Quezon City), with
Ms. Joy Ferriols-Pavico, Center for Environment and Sustainable
Development Foundation, Inc. (CESD)
 Professor Laufred I. Hernandez, University of the Philippines Manila
 Dr. Nymia Pimentel-Simbulan, University of the Philippines Manila
Funding Support:




NIDA (Strathdee T32 DA023356)
University of California’s Pacific Rim Research Program
UCLA International Institute
UCLA Graduate Div. to Community Health Science Dept’s Doctoral Training in
the Social & Behavioral Determinants of HIV/AIDS Prevention (Morisky)
Special Thanks: Abby Rudolph, Ph.D., Tommi Gaines, Ph.D., UCSD, & the
research participants!
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