Socio-structural and Individual Determinants of HIV Risk among Female Entertainment Workers in the Philippines: A Multilevel Analysis

Previous studies only partially explain the variance in condom use behavior among high-risk groups. In low income countries, social-structural factors rather than individual factors alone might better explain the variance in safer sex behaviors among sex workers. This study seeks to determine whether social and structural influence factors, moderated by individual characteristics, are important for female entertainers working in night clubs, spas/saunas, and karaoke bars with regard to HIV risk behavior in the Philippines.;To examine social and structural influences, this study draws upon the theoretical constructs of social cognitive theory and the theories of reasoned action and planned behavior that may explain interpersonal and individual determinants of risk behavior, institutional theory that addresses organizational factors, and the theory of gender and power to explain social dynamics. An assumption underlying this study is that the entertainers' sexual risk behaviors are influenced by peers, managers, and organizational policies of the workplace. Interpersonal and organizational influences interact to influence risk behavior of entertainers, and may be modified by depression, substance use, and social support.;Four-hundred ninety-eight entertainers from 54 establishments and managers in 47 establishments in Quezon City, Metro Manila, the Philippines, were interviewed for this dissertation study, using structured surveys, in addition to focus groups and key informant interviews conducted prior to survey administration. The study utilized three types of multivariate regressions: linear regression (for condom attitudes and consistent condom use), logistic regression (for condom use negotiation), and multilevel modeling to control for individuals nested within establishments. Multiple imputation methods were conducted for missing variables and compared with non-imputed models.;Findings indicate better condone attitudes among entertainers with social support vs. manager support alone, and poorer condom attitudes for those using drugs. Entertainers used condoms more consistently with casual partners and when they had more peer support for condoms. Condom negotiation was higher with casual partners than with regular partners, in establishments with a rule supporting condom use, and with less frequent drug use. Those who had both casual and regular partner types negotiated more when they were not depressed and when they drank alcohol less frequently. They negotiated more with their causal partners than their regular partners, and with increased peer and manager support. Entertainers with the condom attitude that "condom use depended on men in their culture" tended to negotiate condoms less with their partners. In a sub-analysis, predictors of depression included histories of sexual and emotional abuse and alcohol use.;Although the managers held attitudes that supported condom use and their workers' health, few managers in the study discussed condom use with their workers. Also, Kappa statistics revealed that agreement between the managers' and workers' reports about condom use rules and condom availability in their establishments was not higher than would be expected from chance alone. Results suggest a need for multilevel interventions among entertainment workers and their managers that incorporate workplace and city health department policy and address the impact of depression, drug use, sexual and emotional abuse, social support, partner type, and gender related societal norms for condom use.