Community health psychology provides a framework for local citizens themselves to systematically affect change in health and social inequalities, particularly through Participatory Action Research (PAR). The Cambodian NGO SiRCHESI launched a 24-month Hotel Apprenticeship Program (HAP) in 2006 to provide literacy, English, social skills, health education, hotel skills-training, work experience and a living wage to women formerly selling beer in restaurants; there they had faced workplace risks including HIV/AIDS, alcohol overuse, violence and sexual coercion. Quantitative and qualitative analyses indicate changes in health-related knowledge, behaviour, self-image and empowerment, as HAP trainees were monitored and evaluated within their new career trajectories.

This case study illustrates a participatory framework for confronting critical community health issues using "grass-roots" research-guided community-defined interventions. Ongoing work in Cambodia has imported research, theory and practice into the community of Siem Reap, culturally adapting them for particular, local health-promotion responses to HIV/AIDS, alcohol abuse and other challenges. For developing countries such as Cambodia, we recycle such "older" concepts as "empowerment" and "action research". Community health psychology, confronted with "critical", life-and-death issues, can adjust its research and practices to local ontological and epistemological urgencies of trauma, morbidity and mortality, when death has become the dependent variable.

BackgroundFollowing Cambodia’s implementation of the 100% condom use program with enforcement of condom use and STI treatment services for sex workers in 2001, sexually transmitted infection and HIV declined markedly. In 2008, Cambodia implemented a law to ban brothel-based sex work. We reported trends in unprotected vaginal intercourse with sex workers among heterosexual men buying sex before (2003–2008) and after (2009–2012) the brothel ban in Cambodia. We also determined the association of brothel ban with these men’s reports of unprotected intercourse with sex workers.MethodsIn this serial cross-sectional study, we collected yearly behavioural data on random cross-sectional samples of heterosexual men buying sex who attended the only government health centre in Siem Reap for voluntary confidential counselling and testing (VCCT) between 2003 and 2012. We used multivariable Poisson regression analysis on the 10-year data of 976 men to obtain the adjusted prevalence ratio (aPR) of unprotected intercourse in the last 6 months by brothel closure.ResultsMen buying sex from non-brothel-based sex workers increased almost 3-fold from 17% in 2007–2008 before brothel closure to 55% in 2011–2012 after brothel closure (p < 0.001). Unprotected intercourse with sex workers in the last week increased significantly from 37% (2003–2004) before brothel closure to 65% (2011–2012) after brothel closure. This increase corresponded closely with the increase in self-reported unprotected intercourse from 35% to 61% by the sex workers (n = 1805) attending the same clinic for VCCT. Brothel closure was associated with an increased risk (aPR: 1.65; 95% CI: 1.40–1.94) of unprotected intercourse with sex workers. HIV prevalence in the heterosexual men declined significantly from 26% in 2003–2004 to 4.8% in 2007–2008 and 0 case in 2009–2010 before increasing to 5.6% in 2011–2012.ConclusionOur findings suggest that the brothel ban had led to an increase in unprotected intercourse with all sex workers for men buying sex. This effect could be attributed to reduced condom access, a consequence of the lack of feasibility to implement the 100% condom use program following the brothel ban. The ban on brothels in Cambodia should be reviewed.

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Résumé En 2000, l’ ong (organisation non gouvernementale) cambodgienne s i rchesi (Citoyen(ne)s de Siem Reap pour la santé, l’éducation et les questions sociales) s’est intéressée de près au problème du vih /sida 2 et a pu constater que les vendeuses de bière se trouvaient particulièrement affectées par ce virus. Ces femmes, déjà exposées, par leur métier, à la violence et aux abus sexuels, étaient contraintes d’absorber des quantités d’alcool à la fois dangereuses et nocives et, sous-payées, de prendre le risque de se vendre. On leur refusait l’accès au traitement antirétroviral hautement actif ( taha 3 ). L’ ong , en appliquant la recherche-action, met en place les initiatives et programmes locaux dont les objectifs sont, d’une part, d’inciter les brasseurs internationaux à prendre toutes leurs responsabilités en matière de santé et de sécurité de ces travailleuses et, d’autre part, de mettre un terme à l’inégalité de genre, en particulier en ce qui concerne l’administration du taha 4 .