Development and evaluating effectiveness of the personal resilience and enrichment programme (PREP) for mental health and HIV prevention among female sex workers in Hong Kong

Abstract

Female sex workers (FSWs) have been considered a key population in HIV prevention, and current behavioural prevention programmes seem to be effective but unsustainable. Therefore, this study aims to evaluate a resilience-promoting intervention targeting both mental health and safe sex practices among FSWs through a randomised controlled trial.

Prior to the trial, a systematic review was conducted to examine the link between psychological health and condom use among FSWs. Eight papers were identified, and they showed significant associations between FSWs’ poor psychological health and inconsistent condom use. A qualitative study was then carried out with 23 FSWs to explore their resilience. The results informed the design of the Personal Resilience and Enrichment Programme (PREP) for this vulnerable population.

The randomised controlled trial was conducted at three Hong Kong nongovernmental organisations (NGOs), namely Action for REACH OUT, JJJ Association, and the Society of Rehabilitation and Crime Prevention. A total of 127 FSWs, aged 18 years or older who had worked as sex workers in the previous 6 months, were recruited, with 63 in the intervention group and 64 in usual care (control) according to a predetermined, computer-generated randomisation list. The 6-session PREP was designed to improve the resilience, coping skills, self-esteem, and self-efficacy of FSWs. Participants in the control group received standard services, which included outreach visits, screening for HIV or sexually transmitted infections, and social activities provided by NGOs. The group facilitator and participants were unmasked to group allocation.

The complex intervention evaluation framework was adopted to assess the effectiveness and process of the present trial. All participants completed the same questionnaire at baseline, post-treatment, and at 3-month follow up, with assistance from an independent researcher. The safe sex practice was measured by condom use in the last transaction; the psychological measures included the 12-item General Health Questionnaire, the 4-item Perceived Stress Scale, Connor-Davidson Resilience Scale, Brief-COPE, Rosenberg Self-esteem Scale, and the Generalised Self-efficacy Scale. Group differences were analysed with the intention-to-treat analysis, using repeated measures ANOVA or chi-square tests where appropriate. The process evaluation included regular meetings with NGOs and a focus group with participants. Multiple mediation analysis was performed to examine how the intervention reduced psychological distress through resilience factors. Significant improvement in adaptive coping and reduction in psychological distress were found in the intervention group, as compared with the control post-intervention and at 3-month follow up. The scores on resilience and on self-esteem also improved over time across groups. Condom use in the last transaction did not significantly improve after intervention, but condom use in the previous week increased at follow up. The total indirect effect of the multiple mediation model was significant, whereas self-esteem and resilience significantly mediated the effect of intervention on reduced psychological distress. The findings suggest that the PREP is effective in improving psychological status among Chinese FSWs. Overall, in view of FSWs’ increased psychological distress and its influence on HIV risk behaviours, it is recommended to implement mental health services and explore interventions that address both their psychological health and sexual health.