Determinants of Safer-Sex Behaviors of Brothel Female Commercial Sex Workers in Jakarta, Indonesia.The first case of AIDS in Indonesia was found in 1987, and by December 1998 the official number of reported HIV-1-positive cases was 819, of which 227 were full-blown AIDS cases (Ministry of Health, 1998). There is no doubt that these numbers represent an undercounting; however, the available surveillance system in Indonesia did not allow us to approximate the HIV-1 seroprevalence seroprevalence Immunology The proportion of a population that is seropositive–ie, has been exposed to a particular pathogen or immunogen; the seropositivity of a population is calculated as the number of individuals who produce a particular antibody divided in this country. Since heterosexual heterosexual /het·ero·sex·u·al/ (-sek´shoo-al) 1. pertaining to, characteristic of, or directed toward the opposite sex. 2. one who is sexually attracted to persons of the opposite sex. transmission of HIV-1 is the predominant mode of transmission in Indonesia, female commercial sex workers constitute one of the communities at high risk to become infected in·fect tr.v. in·fect·ed, in·fect·ing, in·fects 1. To contaminate with a pathogenic microorganism or agent. 2. To communicate a pathogen or disease to. 3. To invade and produce infection in. with and to transmit the HIV-1 virus. Yearly surveys on the prevalence of gonorrhea gonorrhea (gŏnərē`ə), common infectious disease caused by a bacterium (Neisseria gonorrhoeae), involving chiefly the mucous membranes of the genitourinary tract. and syphilis syphilis (sĭf`əlĭs), contagious sexually transmitted disease caused by the spirochete Treponema pallidum (described by Fritz Schaudinn and Erich Hoffmann in 1905). among brothel and nonbrothel female sex workers in Jakarta repeatedly showed high prevalence of both diseases (18-25% and 5-7%, respectively) (Gunawan, 1997; Van der Sterren, Murray, & Hull, 1995). Furthermore, the 1992 and 1994 HIV-1 seroprevalence surveys in female sex worker communities in Jakarta also indicated an increase in HIV-1 prevalence from 0.3% to 0.6% (Dinas Kesehatan DKI DKI Dynamic Keyword Insertion DKI Disaster Kleenup International (Wood Dale, IL) DKI diffusional kurtosis imaging DKI Don't Knock It DKI Device Kernel Interface Jakarta, 1994). These are indications that sex workers in Jakarta practice unsafe sex behaviors. A study in East Java East Java (Indonesian: Jawa Timur) is a province of Indonesia. It is located on the eastern part of the island of Java and also includes neighboring Madura and Bawean islands. province (population 33 million) showed that 7% of men aged 15 to 60 years had ever had sex with a sex worker (Linnan, Kestari, & Kambodji, 1995). Nearly all major cities in Indonesia This is a list of cities in Indonesia, by major island or region: Java and Bali
adj. Having sufficient grounds for justification; possible to justify: justifiable resentment. jus . The current culturo-political situation in Indonesia, however, still prevents a public safer-sex campaign (KOMPAS, November 7, 1995); therefore, considerable efforts targeted at brothel communities (i.e., the female sex workers themselves, the managers, and the clients) are more feasible and could have a substantial effect on the predicted AIDS epidemic in this country. Studies have shown that inconsistent condom 1. condom - The protective plastic bag that accompanies 3.5-inch microfloppy diskettes. Rarely, also used of (paper) disk envelopes. Unlike the write protect tab, the condom (when left on) not only impedes the practice of SEX but has also been shown to have a high failure use is ineffective in reducing the risk of STDs or AIDS infection (Ford & Wirawan, 1996; Sawanpanyalert, Ungchusak, Thanprasertsuk, & Akarasewi, 1994; Taha et al., 1996; Zenilman et al., 1995). Therefore, although it has also been calculated that in a place where HIV-1 prevalence is still low, any increase in condom use will somewhat reduce the risk of infection (Fineberg, 1988), consistent condom use is the ultimate behavioral change. Accordingly, this study focused on consistent use during sexual intercourse sexual intercourse or coitus or copulation Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). . The government policy toward female sex workers is mainly to rehabilitate re·ha·bil·i·tate v. 1. To restore to good health or useful life, as through therapy and education. 2. To restore to good condition, operation, or capacity. and resocialize them (Dinas Sosial DKI Jakarta, 1993; Jones, Sulistyaningsih, & Hull, 1995). Throughout the country, there are 22 rehabilitation rehabilitation: see physical therapy. centers for sex workers run by either the national or the provincial government. The Jakarta Social Welfare Office (referred to as "the Office") runs one such center in Kramat Tunggak, Northern Jakarta. Here, female sex workers and brothel managers are still allowed to carry out their business, albeit under some regulations and restrictions. Since the Office exercises substantial control over the Kramat Tunggak brothel complex, its policies and programs for the sex workers, managers, and clients, or the lack thereof, may be influential determinants of the sex workers' safer-sex practice. The office provided a monthly health service to the sex workers, which the women were required to attend. Those who refused to come, however, were not penalized pe·nal·ize tr.v. pe·nal·ized, pe·nal·iz·ing, pe·nal·iz·es 1. To subject to a penalty, especially for infringement of a law or official regulation. See Synonyms at punish. 2. . Although the Office had no well-planned STD/AIDS-related educational programs in addition to this health program, condoms were occasionally mentioned in their regular talks, which were attended each time by about 100 sex workers and a few brothel managers. Other powerful decision makers in a brothel complex are the brothel managers and the clients (Swaddiwudhipong, Chaovakiratiping, Sift, & Lerdlukanavonge, 1990). Client-related factors, such as types of clients, clients' attitudes toward condom use, number of clients, and price per sexual encounter may be important determinants for the sex workers' consistent condom use (Mhalu et al., 1991; Picketing picketing, act of patrolling a place of work affected by a strike in order to discourage its patronage, to make public the workers' grievances, and in some cases to prevent strikebreakers from taking the strikers' jobs. Picketing may be by individuals or by groups. , Quigley, Hayes, Todd, & Wilkins, 1993). In addition, certain sociodemographic factors, such as age, educational attainment Educational attainment is a term commonly used by statisticans to refer to the highest degree of education an individual has completed.[1] The US Census Bureau Glossary defines educational attainment as "the highest level of education completed in terms of the , hometown home·town n. The town or city of one's birth, rearing, or main residence. Noun 1. hometown - the town (or city) where you grew up or where you have your principal residence; "he never went back to his hometown again" , and years of working as a sex worker, may also influence safer-sex behaviors (Pickering et al., 1993; Wilson, Sibanda, Mboyi, Msimanga, & Dube, 1990). METHODS Participants Our study population was the female sex worker community in Kramat Tunggak, Northern Jakarta. Since Kramat Tunggak is a unique place, a brief description is necessary. It has a total area of 11.5 hectares (approximately 28.4 acres) and is semi-isolated from the surrounding residential neighborhoods by a two-meter-high brick wall. Officially, only the sex workers are allowed to live there; the brothel managers are only permitted to come on a daily basis, and no children are allowed to enter. In reality, however, many of the brothel managers live there with their families and bodyguards. The complex is guarded by official civil guards who are posted at the two main entrance gates, which abut To reach; to touch. To touch at the end; be contiguous; join at a border or boundary; terminate on; end at; border on; reach or touch with an end. The term abutting implies a closer proximity than the term adjacent. two spacious parking lots available for Kramat Tunggak guests only. On average, each brothel manager employs 5 to 10 sex workers; usually these women have to pay the managers for their room, water, and electricity. The women also have to share their earnings with their managers, as the clients pay the women directly. The percentage varies according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. each brothel, but 25% for the managers is the average proportion (Sedyaningsih-Mamahit, 1997). The Office is located across the street from the brothel complex. The rehabilitation and resocialization programs include some vocational training classes, such as literacy, sewing sewing: see needlework. , and cooking, which are held in an adjacent building. Measures This study used the AIDS Risk Reduction Model (ARRM ARRM AIDS Risk Reduction Model ARRM Army Range Requirements Model ARRM Advanced RTS Response Module ) (Catania, Kegeles, & Coates, 1990) with the inclusion of elements of the Health Belief Model (HBM HBM Human Body Model HBM Human Brain Mapping HBM Hottinger Baldwin Messtechnik GmbH (German company) HBM High Bone Mass HBM Hybrid Bilayer Membrane HBM Humming Bird Medal HBM Her/His Britannic Majesty ) (Janz & Becker, 1984) and Bandura's concept of self-efficacy theory (Bandura ban`dur´a n. 1. A traditional Ukrainian stringed musical instrument shaped like a lute, having many strings. , 1989). The questionnaire was developed through several stages with the help of experts and the use of several other researchers' questionnaires as models and/or comparisons (Basuki, 1991; Rahardjo, 1992; Wingood & Case, personal communication, 1994). It is based on theories and models used in developing questions, both general and behavioral (Ajzen & Fishbein, 1980; Bandura, 1977, 1989; Catania et al., 1990; Fowler & Mangione, 1990; Janz & Becker, 1984), and on preliminary qualitative research Qualitative research Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections. conducted at the study site in June and July, 1993. The questionnaire assessed the following: (a) sociodemographics, (b) occupational-related information, (c) STD/AIDS-related behavioral information, and (d) other health risk behaviors. To improve accuracy, questions about condom use referred to the previous two weeks only. Condom use was initially measured as a percentage (i.e., the number of clients who used condoms divided by the number of all clients). This was based on the assumption--supported by the preliminary study--that most sex workers had only one intercourse per client. The term client encompassed all males who received sex services from the sex workers, including occasional clients (tamu), regular clients (kenalan), and the women's lovers (gendak). Procedure Respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. for the survey were randomly chosen (using a random number list) from the sex worker name list recorded by the Office in April, 1995. At that time, 1,600 women and 228 brothel managers were officially registered in Kramat Tunggak. The only exclusion criterion for our survey was if the sex workers had been trained by Yayasan Kusuma Buana (YKB YKB Yapý Kredi Bankasý (Turkey) ), a nongovemment organization that had given about 80 sex workers a 3-day intensive STD/AIDS training course in 1994 (Sasongko, personal communication, 1995). Ten women, ages 20 to 30, conducted the face-to-face interviews. Using an available area map, our team visited the first 500 selected sex workers in their brothels BROTHELS, crim. law. Bawdy-houses, the common habitations of prostitutes; such places have always been deemed common nuisances in the United States, and the keepers of them may be fined and imprisoned. 2. during the daytime. Those who refused to participate and those who were not found after two visits were dropped, and other names were selected randomly to replace them using the random number list. Most of the sex workers who agreed to participate fully in the study signed or fingerprinted a written consent; only a few agreed verbally. After one and a half months (May-June 1995), data were obtained from 459 survey respondents. The initial response rate was 63%: About 5% of the nonrespondents refused to participate, while the rest (32%) were either not present or were not recognized in that brothel (the original Office name list was handwritten hand·write tr.v. hand·wrote , hand·writ·ten , hand·writ·ing, hand·writes To write by hand. [Back-formation from handwritten.] Adj. 1. and sometimes hard to read). To estimate the reproducibility of data on consistent condom use, a 2 week test-retest reliability test-retest reliability Psychology A measure of the ability of a psychologic testing instrument to yield the same result for a single Pt at 2 different test periods, which are closely spaced so that any variation detected reflects reliability of the instrument assessment was conducted on a random subset A group of commands or functions that do not include all the capabilities of the original specification. Software or hardware components designed for the subset will also work with the original. of the sample (N = 46), while their validity was estimated by comparing them with condom use data obtained in 2-week diaries, filled out by a small number (N = 40) of participants randomly chosen from the survey participants. For two weeks, these women were asked to afix a green sticker with a man's picture on it for every client she had sex with; a red sticker with the picture of a heart on it for every sex act with a lover; and a yellow sticker with a picture of a condom on it beside the stickers of the clients and lovers when they used a condom in intercourse. They were also asked to collect their used condom wrappers In data mining and treatment learning, wrappers were used by Ron Kohavi and George John. Their idea was to wrap their treatments learners in a preprocessor that would search to make subsets from the current set of attributes. to be matched with their condom use records in the diaries. Test-retest reliability analysis showed that the sex workers' self-reported condom use showed a moderate reproducibility, with Spearman spear·man n. A man, especially a soldier, armed with a spear. correlation estimated as 0.38 (p [is less than] .04). The relative validity--comparing self-reported data with diary data--was also moderate. The Spearman correlations were estimated as 0.61 (p [is less than] .004) and 0.52 (p [is less than] .02). As we realized that the sex workers might be telling us what they believed we wanted to hear, we also conducted an extensive qualitative study. This was carried out between April and November of 1995, mainly by the primary investigator. Respondents were chosen using predetermined pre·de·ter·mine v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines v.tr. 1. To determine, decide, or establish in advance: criteria, (such as age, sex, and size of brothel) from among the sex workers, the brothel managers and bodyguards, the clients (convenience samples), the vocational trainers, and government officers (see Sedyaningsih-Mamahit, 1997 for findings from this qualitative study). Statistical analyses Data were initially recorded in Epi-Info (Center for Disease Control, 1990). Univariate, bivariate bi·var·i·ate adj. Mathematics Having two variables: bivariate binomial distribution. Adj. 1. and multivariate The use of multiple variables in a forecasting model. analyses were carried out using STATA (STATA, 1993). Our main outcome variable was consistent condom use. Condom use was classified as 0 (never), 1 (seldom), 2 (often), or 3 (always) and for the final analysis, into 1 for always and 0 for others. The association of consistent condom use with other variables was estimated by odds ratios in logistic regressions In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . The sample size varied because of missing data: Condom use was reported only by those indicating vaginal vag·i·nal adj. 1. Of or relating to the vagina. 2. Relating to or resembling a sheath. vaginal pertaining to the vagina, the tunica vaginalis testis, or to any sheath. sex during the previous two weeks. Condom use reproducibility and validity was assessed by Spearman correlation coefficients Correlation Coefficient A measure that determines the degree to which two variable's movements are associated. The correlation coefficient is calculated as: between self-reported and retest re·test tr.v. re·test·ed, re·test·ing, re·tests To test again. n. A second or repeated test. data, and between self-reported and diary data. RESULTS Descriptive Analysis Sociodemographic characteristics. In general, the characteristics of our study samples, the sex workers who refused to become respondents, and the entire Kramat Tunggak sex worker population (data from the May, 1993 census) are quite similar. Table 1 indicates that we surveyed more educated sex workers as respondents (4.7% or n = 18 attended senior high school), compared to the nonrespondents (1.5% or n = 4), a very likely scenario, as it is likely that they have more self-confidence. Table 1. Comparisons Among Nonrespondents, Respondents, and the Sex Worker Population in Kramat Tunggak (KT), by Sociodemographic Characteristics.
Sample
Respondents Nonrespondents
Characteristics n = 459 (%) n = 270(a)(%)
Age (in years)(c)
[is less than or equal to] 20 99 (22%) 51 (19%)
21 - 25 208 (45) 136 (50)
> 25 152 (33) 83 (31)
Education Attained(c,d)
No school 32 (7) 4 (1)
Elementary
([is less than or equal to] 6
years) 362 (79) 251 (94)
Jr high school (> 6-9 y) 44 (9) 11 (4)
Sr high school (> 9-12 y) 21 (5) 4 (1)
Marital Status(c)
Never married 56 (12) NA
Divorced/widowed 379 (83) NA
Married 24 (5) NA
Years working in KT(c,d)
0 - 1 years 274 (60) 207 (77)
1 - 2 years 108 (23) 53 (19)
> 2 years 77 (17) 10 (4)
Hometown
West Java & Jakarta 241 (53) 156 (58)
Central Java &
Yogyakarta 143 (31) 80 (30)
East Java & elsewhere 75 (16) 34 (12)
Whole
Population
Characteristics n = 1977(b) (%)
Age (in years)(c)
[is less than or equal to] 20 595 (30%)
21 - 25 917 (46)
> 25 465 (24)
Education Attained(c,d)
No school 174 (9)
Elementary
([is less than or equal to] 6
years) 1688 (85)
Jr high school (> 6-9 y) 99 (5)
Sr high school (> 9-12 y) 16 (1)
Marital Status(c)
Never married 694 (35)
Divorced/widowed 1283 (65)
Married 0 (0)
Years working in KT(c,d)
0 - 1 years 983 (50)
1 - 2 years 615 (31)
> 2 years 379 (19)
Hometown
West Java & Jakarta 1097 (56)
Central Java &
Yogyakarta 597 (30)
East Java & elsewhere 283 (14)
(a) Kramat Tunggak Name List, April 1995. (b) Kramat Tunggak Census, May 1993. (c) Difference between respondents and the whole population significant at p < .05 (Chi-square test chi-square test: see statistics. ), (d) Difference between respondents and non-respondents significant at p < .05 (Chi-square test). The government policy regarding marital status marital status, n the legal standing of a person in regard to his or her marriage state. may explain the difference between our respondents and the general Kramat Tunggak population. This policy only allows divorcees, widows, and nonvirgin unmarried women ("holed girls" or gadis bolong is the official term for these women) to work as sex workers in Kramat Tunggak: Virgins and married women are prohibited pro·hib·it tr.v. pro·hib·it·ed, pro·hib·it·ing, pro·hib·its 1. To forbid by authority: Smoking is prohibited in most theaters. See Synonyms at forbid. 2. . It was no surprise, therefore, to see that no married women were officially registered; nevertheless, interviews revealed that married women did work in Kramat Tunggak (5.2% or n = 24). Data on the number of years worked in Kramat Tunggak show that we missed more new sex workers; again, a very likely scenario since they were probably afraid of us. More than 80% (n = 382) of the sex workers had worked for 2 years or less in Kramat Tunggak. This finding was not only in accordance with the Kramat Tunggak census, but also with data on other brothel complexes in Jakarta (Basuki, 1991). Occupational-related characteristics. The respondents' occupational-related characteristics are displayed in Table 2. Most of the sex workers in Kramat Tunggak came from poor families, so it was not a surprise to learn that about 63% (n = 291) were motivated by reasons that included economics. Motivation was determined using an open-ended question A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a , in which the women could relate their personal stories. In Indonesia, where being a sex worker is highly stigmatized, it is interesting to see that 13% (n = 60) of the women frankly stated that they chose, and were not forced into, sex work. Nearly 15% (n = 67) also mentioned that they enjoyed working as sex workers. The remaining sex workers' motivations to enter the job included disharmony dis·har·mo·ny n. 1. Lack of harmony; discord. 2. Something not in accord; a conflict: "the disharmonies that assail the most fortunate of mortals" Peter Gay. with their significant men and other stressful conditions (24% or n = 108). Previous experience of being raped was not a commonly reported "push" factor: Only 5 % (n = 25) of the sex workers reported being raped before entering prostitution prostitution, act of granting sexual access for payment. Although most commonly conducted by females for males, it may be performed by females or males for either females or males. . Table 2. Measures of Occupational-Related Characteristics of The Sex Worker Respondents in Kramat Tunggak
Variable n = 459 (%)
Occupational-Related Characteristics
Age when started working as sex worker
Range 11 - 32.0 y
Mean 22.0 y
SD 3.6 y
Reason works as sex worker
Economic reason only 188 (41)
Combination of economic & other reasons 103 (22)
Dispute with husband/boyfriend, being sold/
cheated, and other stressful conditions 108 (24)
Tempted by others and self-motivated 60 (13)
Monthly income as sex worker(a)
[is less than or equal to] $ 45.00(b) 8 (2)
> $ 45.00 - $136.00 130 (28)
> $136.00 - $ 227.00 130 (28)
> $ 227.00 - $ 454.00 145 (32)
> $ 454.00 46 (10)
Types of Sexual Services (previous 2 years)
Vaginal sex
Never 27 (6)
Seldom 7 (1)
Sometimes 8 (2)
Often 30 (7)
Always 387 (84)
Anal sex
Never 459 (100)
Oral sex
Never 452 (96)
Seldom 2 (1)
Sometimes 2 (1)
Often 2 (1)
Always 2 (1)
Manual sex (i.e., hand masturbation)
Never 388 (85)
Seldom 43 (9)
Sometimes 15 (3)
Often 11 (2)
Always 2 (1)
Number of clients(c) (within previous 2 weeks)
None 27 (6)
<7 264 (58)
7-14 31 (26)
15-21 39 (8)
>21 9 (2)
Condom use with clients(d)
(within previous 2 weeks)
Never 108 (25)
Seldom 96 (22)
Often 74 (17)
Always 154 (36)
Related to Safer-Sex Practice(d)
Self-efficacy in using condoms
Low 202 (46)
High 230 (53)
Experience in negotiating condom use
Low 281 (65)
High 151 (35)
Experience in using condoms for family planning
Yes 11 (3)
No 421 (97)
Perception of clients and managers
attitudinal barriers
Low 172 (40)
High 260 (60)
(a) $1.00 = Rp. 2200.00 (1995). (b) The average wage of a woman factory worker. (c) Includes occasional and regular customers, and lovers. (d) N = 4322 (excludes the sex workers who had no clients). More than half the women had tried different jobs before entering the sex industry; working in a factory was the most popular job. From the qualitative study we found that not only did these jobs yield much less money (the average wage was $45.00 per month), but the working hours were also much longer than commercial sex work. Although only 59% (n = 269) of the women adopted at least one measure to prevent pregnancy, 12.4% (n = 57) had induced abortion in·duced abortion n. Abortion caused intentionally by the administration of drugs or by mechanical means. induced abortion . The seemingly seem·ing adj. Apparent; ostensible. n. Outward appearance; semblance. seem  ing·ly adv. low number of unwanted pregnancies unwanted pregnancy Obstetrics A pregnancy that is not desired by one or both biologic parents. See Teen pregnancy. may be due to the sex
workers habit of drinking traditional herbs, or to pelvic inflammatory
disease pelvic inflammatory disease (PID), infection of the female reproductive organs, usually resulting from infection with the bacteria that cause chlamydia or gonorrhea. (PID (1) (Process IDentifier) A temporary number assigned by the operating system to a process or service.(2) (Proportional-Integral-Derivative) The most common control methodology in process control. ) as a complication complication /com·pli·ca·tion/ (kom?pli-ka´shun) 1. disease(s) concurrent with another disease. 2. occurrence of several diseases in the same patient. com·pli·ca·tion n. of repeated STDs. Features of the sex workers sexual behaviors sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. showed their practices over the previous two years and some over the previous two weeks. In line with others unpublished findings (Basuki, 1991; Rahardjo, 1992), we too found that vaginal sex was the most preferred type of sex, and no one reported having anal sex Noun 1. anal sex - intercourse via the anus, committed by a man with a man or woman anal intercourse, buggery, sodomy sexual perversion, perversion - an aberrant sexual practice; . The 5.9% (n = 27) who said they had not had vaginal sex over the previous two weeks were sex workers who for various reasons did not receive any clients during that time. More than half of the women had had fewer than 7 clients in the previous two weeks (this finding was similar to that from another study of a different Jakarta brothel complex by Basuki, 1991). This was due to the fact that many clients come just to drink beer and to dance, and many of the women only gave sexual service to regular customers or lovers, who would visit and pay on a regular basis. One percent (n = 5) of the women said that they had never seen a condom before; all of them were new to the job. An estimated 36% (n = 154) of the sex workers said that they required their clients to use a condom all the time, and 25% (n = 108) said they never required their partners to use condoms when engaging in vaginal intercourse. Predictors of Consistent Condom Use Before adjusting for other factors, several variables were significantly associated with consistent condom use. In the multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. , however, some of those associations became statistically insignificant. In multivariate logistic regression analysis, all statisttically significant factors (p [is less than] .05) from the bivariate analyses--as well as other factors that we thought were conceptually important in predicting consistent condom use--were initially included in the model. Hence, we were testing the direct association between factors from the three different stages of the AIDS Risk Reduction Method and consistent condom use. Variables that remained significant--as well as factors that are conceptually important--were kept in the final model. Thus, we ended up with one final model to predict consistent condom use (see Table 3). Table 3. Estimated Odds Ratio From Multiple Logistic Regression Predicting Consistent Condom Use Among Sex Workers in Kramat Tunggak.
Predictive Variable(a) Consistent condom use
OR(b) 95% CT(c)
Sociodemographic Factors
Age (years)
[is less than or equal to] 20(d) 1.00
21 - 25 1.31 0.68 - 2.53
> 25 1.40 0.69 - 2.82
Education attained
No school(d) 1.00
Elementary 0.98 0.39 - 2.49
Jr High School 0.46 0.14 - 1.50
Sr High School 0.42 0.09 - 1.86
Hometown
West Java & Jakarta(d) 1.00
Central Java & Yogyakarta 1.81 1.04 - 3.15
East Java & elsewhere 1.08 0.54 - 2.14
Years working in KT
[is less than or equal to] 1(d) 1.00
1 - 2 1.06 0.60 - 1.88
> 2 0.18 0.07 - 0.43
Sex Workers' Personal Determinants
Self-efficacy in carrying out the
intention to do safer sex
Low(d) 1.00
High 1.61 0.94 - 2.75
Experience in negotiating condom use
Low(d) 1.00
Med 1.76 0.75 - 4.12
High 5.15 2.16- 12.25
Experience in using condoms for
family-planning purposes
Nod 1.00
Yes 9.13 1.85 - 45.08
External Factors
Perception of clients' and managers'
attitudinal barriers towards condom use
Low(d) 1.00
Med 0.35 0.20 - 0.62
High 0.13 0.06 - 0.27
Exposure to govt.'s programs
No(d) 1.00
Yes 0.59 0.36 - 0.97
Predictive Variable(a)
p
Sociodemographic Factors
Age (years)
[is less than or equal to] 20(d)
21 - 25 .42
> 25 .35
Education attained
No school(d)
Elementary .96
Jr High School .20
Sr High School .25
Hometown
West Java & Jakarta(d)
Central Java & Yogyakarta .04
East Java & elsewhere .83
Years working in KT
[is less than or equal to] 1(d)
1 - 2 .84
> 2 .0001
Sex Workers' Personal Determinants
Self-efficacy in carrying out the
intention to do safer sex
Low(d)
High .08
Experience in negotiating condom use
Low(d)
Med .19
High .0001
Experience in using condoms for
family-planning purposes
Nod
Yes .007
External Factors
Perception of clients' and managers'
attitudinal barriers towards condom use
Low(d)
Med .0001
High .0001
Exposure to govt.'s programs
No(d)
Yes .04
(a) Initially, we included all statistically significant variables from the bivariate analyses in the multiple logistic regression analysis to follow the hypothesis model (i.e., hometown, length of time working in Kramat Tunggak, knowledge of STDs, knowledge of AIDS, condom acceptance and condom rejection, self-efficacy in using condoms, intention to perform safer sex the next day, self-efficacy in carrying out the intention, previous experience in using [for family planning family planning Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources. purposes] and negotiating condoms, consistent condom provision by the managers, and perceived clients' and managers' attitudinal barriers towards condom use), as well as other factors that were conceptually important for predicting condom use (i.e., age, education attained, and attending the government's programs). Variables with p < .05--as well as others that were conceptually important--were kept in the final model, (b) OR = odd ratio, (c) CI = confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. , (d) Reference. Sociodemographic characteristics. Independent of the other variables in the model, sex workers from Central Java Central Java (Indonesian: Provinsi Jawa Tengah) is a province of Indonesia. The administrative capital is Semarang. It is one of the six provinces of the island of Java. Central Java is both a political entity and a cultural concept. and Yogyakarta were more likely to practice consistent condom use than their colleagues from either West or East Java. The odds that these women practiced consistent condom use were nearly two times their colleagues (OR = 1.8; CI = 1.03 - 3.15). Data showed that the longer the sex workers worked in Kramat Tunggak, the less they would practice consistent condom use. The "longest term" women were about six times less likely to practice consistent condom use when compared to others (OR = 0.18; CI = 0.07 - 0.43). From the qualitative study we learned that the longer-term women usually had regular clients or lovers. Since these were also the clients least likely to use condoms, we suspected that this might be the cause. Another reason may be that these women felt they were experienced enough to select which clients were healthy and which were not, although their concept of healthy was actually "clean in appearance." Another interesting fact was that the higher the women's previous monthly income, the less they would practice consistent condom use (p for trend test [is less than] .002). A similar result was found for the variable number of clients over the previous two weeks: The more clients the women had, the less they practiced consistent condom use (p for trend test [is less than] .006). How much clients pay for sex has been found to be a factor that determines sex workers' condom use (Mhalu et al., 1991; Picketing, Quigley, Hayes, Todd, & Wilkins, 1993). In Kramat Tunggak, however, the prices for different sex services (i.e., short time and overnight) were more or less fixed. Unfortunately, our questionnaire provided limited data about the sex workers' current economic status. Since our income data only referred to the previous month and prices were fixed, this information was more of an indication of the number of clients served by the women than of their economic status. Our income data were positively correlated cor·re·late v. cor·re·lat·ed, cor·re·lat·ing, cor·re·lates v.tr. 1. To put or bring into causal, complementary, parallel, or reciprocal relation. 2. to the number of clients served: The Spearman correlation was 0.39 (p [is less than] .0001). Regression analysis In statistics, a mathematical method of modeling the relationships among three or more variables. It is used to predict the value of one variable given the values of the others. For example, a model might estimate sales based on age and gender. also indicated that every increase of 7 clients was associated with an income difference of Rupiah ru·pi·ah n. pl. rupiah See Table at currency. [Hindi rupay  , rupiy (Rp.) 240,530.00 (approximately $109.00), or about Rp. 34,000.00
per client (approximately $15.00), which is similar to results of the
qualitative study (i.e., the prices for short time and overnight sex
were Rp. 15,000.00, or about $7.00, and Rp. 40,000.00, or about $18.00
respectively). Currency values are based on exchange rates at time of
this study.In the bivariate analysis, the number of clients over the previous two weeks also showed a negative association with consistent condom use: The more clients the women had, the less they practiced consistent condom use (p for trend test [is less than] .006). Therefore, we used only one variable, such as the number of clients, in the multivariate logistic regression. In the multivariate model, the negative association between number of clients and condom use persisted. The cross-sectional study cross-sectional study n. See synchronic study. cross-sectional study, n the scientific method for the analysis of data gathered from two or more samples at one point in time. design, however, did not allow us to estimate a temporal relationship between them. Our qualitative study indicated that many sex workers, in their anxiety over losing their clients, were reluctant to insist that their clients use condoms. We assumed it was more likely that less consistent condom use caused the number of clients to increase, rather than the other way around. As the number of clients was also positively correlated with the number of years of working in Kramat Tunggak (Spearman rho: 0.12, p [is less than] .009), it could also be that many of those clients were either the regulars and/or the lovers, who were less likely to use condoms. Since the reverse causal path was a likely reason for this association, we decided to exclude the number of clients from the final model. The sex workers' personal determinants. In the final model, knowledge about STDs and AIDS, perception of susceptibility susceptibility the state of being susceptible. Refers usually to infectious disease but may be to physical factors such as wetting or to psychological factors such as harassment. and severity of the diseases, attitudes, and self-efficacy in using condoms did not significantly predict consistent condom use. On the other hand, women who had ever used condoms for family planning purposes were 9 times more likely to use condoms consistently (OR = 9; CI = 1.85 - 45.08), and the women most experienced in negotiating condom use were 5 times more likely to practice it consistently than the least experienced ones (OR = 5; CI = 2.16 - 12.25). However, in a separate multiple linear regression Linear regression A statistical technique for fitting a straight line to a set of data points. model with experience in negotiating condoms as the outcome variable and other factors as independent variables, we found that this experience was significantly predicted by knowledge of STDs (p [is less than] .0001), positive beliefs about condoms (p [is less than] .0001), and self-efficacy in using condoms (p [is less than] .0001). External factors. In the final model, one external factor was significantly associated with consistent condom use: Women who perceived the clients' and managers' rejection of condoms as high were eight times less likely to practice consistent condom use than women who perceived the rejection to be low (OR = 0.12; CI = 0.06 - 0.27). It was difficult to separate the clients' attitudes from the managers' in our data; however, the fact that the managers consistently providing condoms in their brothels did not significantly increase the women's consistent condom use might mean that the client factor was the more important one. Since the number of women who received treatment and/or examination from the government monthly mobile service was too small, this variable was dropped, and only the variable of gaining AIDS knowledge from the government's talks was used to represent the influence of government programs. This variable had a negative impact on the sex workers' consistent condom use (OR = 0.58). Further analysis showed that this variable was negatively confounded by multiple factors, such as years of working in Kramat Tunggak and education. As both were inversely in·verse adj. 1. Reversed in order, nature, or effect. 2. Mathematics Of or relating to an inverse or an inverse function. 3. Archaic Turned upside down; inverted. n. 1. associated, it seemed that the longer the women worked in Kramat Tunggak and the higher their level of education, the less likely they would attend the government talks. However, after controlling for these confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor factors, attending the talks was still inversely associated with the women's consistent condom use, suggesting that the government program is ineffective. DISCUSSION We have conducted a behavioral survey among brothel-based female sex workers in Kramat Tunggak, the largest and only official brothel in Jakarta. A large proportion ([+ or -] 28%) of participants were randomly chosen from among the population living and working in the complex, implying representativeness of the data obtained. Realizing that participants might give answers just to please the researchers, we have also conducted an extensive qualitative study to verify certain aspects of the participants' sex behaviors, especially regarding their condom use. We found that only 36% (n = 154) of the participants reported always using condoms during the previous two weeks, 25% (n = 108) never used condoms at all, and the rest (39%) used condoms occasionally. The pattern of condom use in this community was not consistent over time: The reproducibility of these data in test-retest interviews was moderate, and when validated with diary data, showed a moderate correlation. Our qualitative study indicated that this inconsistency in·con·sis·ten·cy n. pl. in·con·sis·ten·cies 1. The state or quality of being inconsistent. 2. Something inconsistent: many inconsistencies in your proposal. was mainly due to real inconsistency in condom use practice, and not because participants lied to us. After adjusting for sociodemographic variables, participants' consistent condom use was significantly and directly associated with their experience in using condoms for family planning purposes and their experience in negotiating condoms with clients in previous times. On the other hand, significant inverse (mathematics) inverse - Given a function, f : D -> C, a function g : C -> D is called a left inverse for f if for all d in D, g (f d) = d and a right inverse if, for all c in C, f (g c) = c and an inverse if both conditions hold. associations were found with the women's length of time as sex workers in Kramat Tunggak, their perceived rejection of clients and managers, and government talks as the source of their AIDS/STD knowledge. Focusing efforts to modify the above factors may substantially change the women's condom use behavior, and may in turn reduce the spread of HIV-1 infection in this community. Trying to work within the existing system, we suggest interventions that place the programs' providers as main actors, involving the sex workers, the clients, and the brothel managers. Although officials publicly state that condom use is promoted in areas with a high rate of prostitution to prevent men from getting AIDS, during the study we found that the government only had two programs to support condom use: the occasional talks and the monthly health services health services Managed care The benefits covered under a health contract . In order to promote condom use and other safer-sex behaviors of the sex workers, the government should develop more aggressive and effective health services and education programs for the sex workers, the brothel managers, and the clients. More regular and systematic talks to smaller groups, preferably based in only one brothel, with more discussions that involve everyone in the brothel including the managers, may be a more constructive way of communicating STD/AIDS knowledge and prevention measures to the sex workers. As condom negotiating and technical skills are important predictors for the women's consistent condom use, they should be included in the training curriculum. Moreover, as previous experiences in using condoms with clients or for family-planning purposes were very significant in promoting consistent condom use, it is best that the government not give sporadic sporadic /spo·rad·ic/ (spo-rad´ic) occurring singly; widely scattered; not epidemic or endemic. spo·rad·ic or spo·rad·i·cal adj. 1. Occurring at irregular intervals. 2. talks or short, intensive condom-training programs, but should have more lengthy regular classes, similar to their other vocational programs Noun 1. vocational program - a program of vocational education educational program - a program for providing education . This way, the sex workers will have a chance to build their self-efficacy in using condoms by practicing their negotiating skills, and to revise them using friends' comments as inputs. In our opinion, a daily clinic located inside the Kramat Tunggak complex would be more effective than a monthly mobile health service: Data showed that only a few sex workers got STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country. examination/treatment from the current monthly service. It should be staffed by doctors, nurses, and other health counsellors who are female, and its services should be both user-friendly and out-reaching. This clinic should primarily address the sex workers' health concerns, which do not necessarily mean STD problems. Only by doing this will the clinic gain the trust of the sex workers. The biggest hindrance hin·drance n. 1. a. The act of hindering. b. The condition of being hindered. 2. One that hinders; an impediment. See Synonyms at obstacle. in setting up the clinic will be the government's reluctance to provide official health services for sex workers out of fear of public protest, since this may be misinterpreted as an act legitimizing prostitution (Sihombing, personal communication, 1995). Nevertheless, if the government is to work toward the women's social rehabilitation and not just oversee a quasi-legal brothel, it must begin to focus on returning healthy women to the community. A health clinic within Kramat Tunggak is a necessary first step in this direction. Another significant factor that hinders the sex workers consistent condom use is the managers' and clients' attitudes toward condom use. To overcome this, the government should have a formal policy on condom use in Kramat Tunggak (and other brothels in Jakarta). In most of the brothels in Kramat Tunggak, one can see signs such as "No guns or sharp weapons allowed," or "Sorry, for security's sake, we will knock on Noun 1. knock on - (rugby) knocking the ball forward while trying to catch it (a foul) rugby, rugby football, rugger - a form of football played with an oval ball rugby, rugby football, rugger - a form of football played with an oval ball your door every half hour." Managers posted these signs to comply with government safety regulations. If managers put up signs stating that condom use is a must in the brothel, the sex workers will then be legally empowered to negotiate condom use with their clients. The managers could also support this by either providing free condoms or by selling condoms in their brothels. Direct programs targeted to clients in the general population are still difficult to launch in Indonesia, since this act will be interpreted as enhancing promiscuity Promiscuity See also Profligacy. Anatol constantly flits from one girl to another. [Aust. Drama: Schnitzler Anatol in Benét, 33] Aphrodite promiscuous goddess of sensual love. [Gk. Myth. . Intervention programs for these men can, therefore, only be conducted in brothel communities and in STD clinics; both still fail to attract the government's current attention. With regard to the brothel communities, billboards and posters to encourage condom use should be put up in brothel complexes. Condom booths, where the clients can buy condoms as well as receive free leaflets about STDs, AIDS, and condoms, should be placed in strategic places inside the complexes. Finally, our study has shown that combining a behavioral survey with a qualitative study enables us to understand the data better. In the future, a survey among the general population surrounding brothel complexes should also be conducted to understand their involvement with the sex workers inside. 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Sexually Transmitted Diseases, 22, 15-21. Manuscript accepted November 23, 1998 Endang R. Sedyaningsih-Mamahit Communicable Disease Research Center, Jakarta, Indonesia Steven L. Gortmaker Harvard School of Public Health, Boston Supported by the government of Indonesia through the Overseas Training Office - National Development Planning Board Noun 1. planning board - a board appointed to advise the chief administrator advisory board governance, governing body, organisation, administration, brass, establishment, organization - the persons (or committees or departments etc. , Jakarta, Indonesia. We are grateful to Dr. K. Heggenhougen, Dr. D. Hunter, Dr. G. Wyshak, and D. Halstead for their contribution to this work. Special thanks go to the team: Dama, Tini, Vita, Tuti, Sofie, Nila, Ipur, Titing, Nia, Mega, Lana, Hikmah, Mar, and Slamet. Finally, we are indebted in·debt·ed adj. Morally, socially, or legally obligated to another; beholden. [Middle English endetted, from Old French endette, past participle of endetter, to oblige to all participants in the field, especially the women of Kramat Tunggak. Address correspondence to Dr. Endang R. Sedyaningsih-Mamahit, DPH DPH Diploma in Public Health. DPH abbr. 1. Diploma in Public Health 2. Doctor of Public Health 3. Doctor of Public Hygiene ; JI. Pendidikan Raya Raya may refer to:
The subdistrict borders the subdistricts of Jatinegara to the west, Cakung and Pulo Gadung to the north, and Makasar to the south. ; Jakarta 13440; Indonesia; e-mail: esedyani@indo.net.id. |
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