A Mobile Intervention to Link Young Female Entertainment Workers in Cambodia to Health and Gender-Based Violence Services: Randomized Controlled Trial

Abstract

Background Female entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance abuse, and gender-based violence (GBV) than the general female population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status. Objective This study evaluated the efficacy of the Mobile Link intervention in improving FEWs’ health by engaging and connecting them to existing HIV, sexual and reproductive health, and GBV services. Methods A randomized controlled trial was conducted between March 2018 and June 2019 in the capital city and 3 other provinces in Cambodia. FEWs in the intervention arm received automated twice-weekly Short Message Service messages and voice messages with health information and direct links to outreach workers. The control group received the existing standard care, including free HIV and STI counseling and testing and a toll-free helpline staffed by trained counselors. We used a stratified random sampling method to select participants from 5 study sites in the 4 selected provinces. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group (18-24 and 25-30 years) and study site using a random number generator and enrolled them in person. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use assessed through a face-to-face structured interview. We also measured secondary outcomes, including contact with outreach workers, escorted referral service use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression. Results A total of 1118 participants were recruited and enrolled in the study. We included 218 FEWs in the intervention arm and 170 FEWs in the control arm in the per protocol analyses after removing 730 dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (at 30 weeks: adjusted odds ratio [AOR] 3.29, 95% CI 1.28-8.47), receiving an escorted referral (at 30 weeks: AOR 2.86, 95% CI 1.09-7.52; at 60 weeks: AOR 8.15, 95% CI 1.65-40.25), and never being forced to drink at work (at 60 weeks: AOR 3.95, 95% CI 1.62-9.60). Over time, no significant differences between intervention and control groups were observed for any primary outcomes in the fully adjusted models. Conclusions The Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals but did not show an effect on primary outcomes. Reduced forced drinking at work was also significantly more extensive in the intervention group than in the control group. Longer-term messaging may increase access to services and impact FEWs’ health outcomes in the future. Trial Registration Clinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842 International Registered Report Identifier (IRRID) RR2-10.1186/s13063-018-2614-7

Post-Gender-Based Violence Services Utilization Among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

“…Since the post-GBV services can often be context-specific due to the country's quality and availability of the existing prevention and services, context-specific interventions are required to improve post-GBV services utilization. For instance, the Mobile Link intervention, an operational mHealth implementation research program linking FEWs in Cambodia to the existing prevention, care, and treatment services, was found to reduce the rate of forced drinking at work, effectively connect FEWs with outreach workers and escort referrals compared to the control group (Brody et al, 2022). Another important implication of this study is mental health support for FEWs, especially those who experienced GBV.…”

Perspectives of Digital Health Innovations in Low- and Middle-Income Health Care Systems From South and Southeast Asia (Preprint)

“…Strategies to reach marginalised populations, including migrants and underserved communities, are imperative. Initiatives such as using mobile phones to deliver health information to key HIV population communities in Cambodia reflect a commitment to advancing health equity [26,54].…”

“…In addition, ensuring participants comprehensively understand the implications of digital health research, especially in linguistically and culturally diverse contexts, is paramount. Countries in the region have taken steps to develop culturally sensitive informed consent processes to uphold ethical standards and respect individuals' autonomy [26]. The digitisation experience of the banking and financial industry in the region can also offer valuable lessons for digital health research and interventions.…”

Connecting Female Entertainment Workers in Cambodia to Health Care Services Using mHealth: Economic Evaluation of Mobile Link

“…Details on the Mobile Link RCT are available in a previously published protocol [8] (trial registration NCT03117842 in ClinicalTrials.gov), and the trial results are presented in separate publications [9,15]. In summary, FEWs were recruited by community health workers in Phnom Penh, Battambang, Banteay Meanchey, and Siem Reap and randomly assigned to the treatment and control arms of the trial.…”