Health Education Research, Vol. 16, No. 3, 321-333,
June 2001
© 2001 Oxford University Press
Occupational health and safety amongst sex workers: a pilot peer education resource
Department of Health Sciences, University of East London, London E15 4LZ, UK
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Abstract |
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This paper presents an account of a pilot project to design and implement an innovative, sex-worker-driven approach to peer education in London. A 28-min, double-sided tape cassette containing extracts of sex workers talking candidly about their work was compiled from oral history recordings. The aims were to pilot process issues in compiling the collaborative resource, and to stimulate discussion of health and safety issues, exploring whether the resource could potentially enhance positive changes in sex workers' knowledge and awareness, self-esteem, and lifeskills. In a limited pilot distribution, 15 sex workers and seven outreach workers in London listened to the tape and completed short evaluation questionnaires. The paper sets out strengths and weaknesses of the pilot method, linking these to broader critical reflections on issues raised about peer education to, for and by sex workers.
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Introduction |
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Peer education has been defined as `peer-to-peer communication' or `an approach whereby a minority of peer representatives from a group or population actively attempt to inform and influence the majority' by the European Joint Action Plan on AIDS Peer Education to reach Young People in and outside the School System [(Europeer, 1998
): 7, 9]. Broadly, it refers to the practice of those of the same societal group or social standing educating each other. Like other target groups, sex workers have been conceived as a marginalized population who are `hard-to-reach' and vulnerable to health risk. Since the AIDS crisis originating in the 1980s, peer education has loosely informed the development of health promotion work with sex workers across the globe (EUROPAP, 1995; Brussa and Mongard, 1998; Wolffers, 1998).
Peer education embraces a range of complex, dynamic methods that are rarely clearly differentiated (Turner and Shepherd, 1999). In response to such confusion, the Europeer project was set up to provide peer education guidance (Europeer, 1998). From a literature review and interviews conducted with AIDS peer education projects in 11 European Union member states, they identified four sub-approaches to AIDS peer education that can usefully be applied in the sex work context.
The `Pedagogic approach' is characterized by peer educators who are the same age as the target group, giving formal lectures using an implicit and explicit language adapted to the target group. Peer educators in this approach rarely belong to the social group receiving the peer education, but share characteristics such as age, ethnic group, sexual orientation or `problem'. The `Outreach approach' is described as based on a similar model, but specifically targets marginalized populations. This is the approach used in most sex worker outreach projects in Europe (EUROPAP/TAMPEP, 1998; EUROPAP, 1999b), where outreach workers working alongside nurses and doctors set up `drop-in' clinics, and visit sex workers in street and in-door locations such as flats and saunas, delivering safer sex supplies, information and support. In the UK, 78 projects that specifically offer sex work outreach services are listed in a EUROPAP directory and most are funded by UK Health Authorities (EUROPAP, 1999a).
The `Diffusional approach' draws on peer educators who belong socially to the target group, and uses existing social networks and communication channels to diffuse change through the group. One European sex work example is the TAMPEP (Transnational AIDS/STD Prevention among Migrant Prostitutes in Europe) model of training migrant sex workers to do formal tutoring or one-to-one counselling with their peers (TAMPEP, 1997).
Lastly, the `Peer-Facilitated Community Mobilization approach' involves a strong coalition of community organizations, opinion leaders, professionals and target group members mobilized to lobby for health, social and legislative reform. The aim is often that target group members (in this case sex workers) can eventually take over responsibility for the project. In the UK context, we might conceive of the English Collective of Prostitutes performing this role, although their enduring policy not to identify whether workers are sex workers or not means it is difficult to say to what extent their work is sex worker driven.
With increasing recognition of the active, willful, moral, reflexive and insightful agency of sex workers (Nagel, 1997; Overs, 1997), peer education hence appears to have clear currency in the sex work context. As with other target groups, it has generally been initiated within a broadly positive and enthusiastic frame (Milburn, 1995), and projects that reflect a clear analysis of the social environment for sex work and an understanding of local organization have been promoted (Wolffers, 1998). The broad promise of the method lies in a range of appealing features that are intellectual (we share attitudes and opinions with people we socialize with), financial (as it often relies on committed volunteers or low paid workers) and emotional (requiring coordinated, consensual activity with altruistic motives) (Hart, 1998).
Although critical analysis has been limited to date, sex work peer education is, however, problematic on a number of levels. Outreach projects have been criticized as being `welfarist'. Whilst they may appear benign, Cohen has argued that they often permit more inclusive and less accountable intrusion into the lives of individuals (Cohen, 1996). In terms of funding policies, it has been suggested by some commentators that intrusion is based on an unstated policy to protect clients from HIV, rather than through any real health concern for sex workers (Alexander, 1996; Overs, 1997). A call for more radical approaches to health promotion and for sex-worker-driven projects is increasingly heard in the UK (Scambler and Scambler, 1998), since in contrast to the US (Leigh, 1996) and other countries (Kempadoo and Doezema, 1998), UK sex work projects that adopt the outreach approach rarely explicitly employ sex workers and ex-sex workers (with the exception of two projects in Scotland) (EUROPAP, 1999a). Another criticism of outreach approaches with sex workers is that they have not permitted cross-fertilization of ideas from other groups of political activists working in allied fields (Overs, 1997). For example, Peter Scott commented on the way that gay men were gradually excluded from AIDS prevention work as it became professionalized (Scott, 1997), but sex work outreach work has not been subjected to the same level of scrutiny.
Outreach projects have also increasingly been criticized for their rather narrow focus on HIV prevention and sexual health. Although by the early 1990s it became clear that voluntary adult sex workers in western countries were not a primary risk in relation to the transmission of HIV and AIDS (Plant, 1990; McKeganey et al., 1992; European Working Group, 1993; Ward et al., 1993) in outreach projects across the globe, sex worker health has become viewed as virtually synonymous with sexual health (Alexander, 1999). This is a view that has been subconsciously adopted by some sex workers themselves. For example, during a 1-week women's empowerment training event for sex workers organized in Katmandu, sex workers asked to spend 1 day talking about health. This included drawing body maps. The course organizers reported that the genital areas were all drawn very large and no other organs were depicted (Boucher and White, 1997). It seems that well-meaning concern risks being translated into new pathology. In an analysis of a UK `in-door' sex worker environment, Whittaker and Hart stressed the importance of broadening the health agenda to encompass occupational health and safety issues, suggesting that sex workers who have the most control over their working conditions are the least vulnerable to violence, sexually transmitted diseases and other health hazards, and have a more balanced view of the dangers faced in their lives (Whittaker and Hart, 1996).
Diffusional peer education projects that train sex workers to work as peer educators have encountered problems with alienation, the creation of low-cost workers and lack of recognition of structural barriers, such as harsh policing regimes and poverty (TAMPEP, 1997; Brussa and Mongard, 1998). Lessons learned are that it is difficult to predict where the real networks in the community are and that if individuals are trained, in presenting themselves as the one who knows everything, they risk isolation and jealousy from the target group. High transitional mobility of sex workers often necessitates continuous repetition of cycles of peer educator activity (TAMPEP, 1997). TAMPEP warn of risks of control and tokenism that are familiar in peer education more widely (Clements and Buczkiewicz, 1993). A further critique is that they can turn peer education practice into `Chinese whispers', where information is modified inaccurately as it diffuses through networks (Turner and Shepherd, 1999).
Like broader peer education initiatives, sex work peer education projects also suffer a lack of theoretical and evaluative credibility. Looking across different target groups, Turner and Shepherd explored a set of claims for peer education that included concepts of modelling, reinforcement, empowerment, self-efficacy and sub-cultural associations (Turner and Shepherd, 1999). Like Kathryn Milburn in her review (Milburn, 1995), they concluded that evidence for a solid theoretical foundation was partial and over-reliance on lay assumptions about theories of learning was evident.
Clearly, further substantial research is needed to explore all these issues. The assumption that forms the basis of the initiative described in this paper is that this in part relies on experimentation with small-scale innovations. This paper sets out one small pilot project undertaken with sex workers in the UK. It takes the reader through the activities involved in conceiving, designing and implementing a `narrative-based', sex-worker-led, peer education resource tape using a `diffusional' approach. Through the cautious reporting of results from a recognizably limited pilot evaluation, it considers the early challenges raised in the context of sex work peer education.
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Method |
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Building a project coalition
Life testimony extracts were drawn from a collection entitled `The Oral History of Prostitution (OHP)' which has involved the creation of an archive containing 30 life history interviews with sex workers and others involved in the `sex industry'. This collection is housed in the British Library National Sound Archive under copyright arrangements specified by the interviewees, primarily as a record of our social history (Rickard, 1998a
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The idea for developing a peer education resource from this material came from the grass roots level. Several sex workers who had already contributed interviews had expressed interest in hearing a selection of the oral history recordings and we had many discussions with them about the possibilities for preparing a health promotion resource that drew on sex worker's own wisdom. In this sense, the project was sex worker driven and sex workers were consulted at every subsequent stage. It fitted with a broadly heralded philosophy of initiating health promotion for and by the target population, exemplifying partnership and inclusion (Watson and Platt, 2000). It also allowed experimentation with techniques for engaging people who give oral history material in reflecting on its content, and determining its format and use (Rickard, 1998b).
Following presentations at health professionals' training events on sex work, in which one of the authors used extracts of recordings from the above collection and mentioned the sex workers' ideas, an outreach worker from a London sex work project contacted us to explore possibilities of setting up such a resource for and by sex workers. From here we set up collaboration with a key gate-keeper at a project with established networks with female sex workers in London. Minimal time-limited funding was obtained through a project entitled `Life Testimony in Health Promotion' (Rickard et al., 1999).
Deciding on pilot tape content and approach
We did some background research to explore whether recorded narrative material had been used before in sex work peer education and found few examples, aside from instructional videos on sex techniques. Plays and sketches, theatre productions, and CD-ROMs have been used by health promoters to create a focus for peer-led discussions, but in the UK examples in the sexual health promotion field have mainly focused on HIV/AIDS prevention more broadly (Cultural Partnerships, 1996; East London and the City Health Authority, 1997; Jubilee Arts, 1998).
The only specific narrative-based sex work example we found in the UK was the `Ugly Mugs' initiative, which relied not on recordings but on written summaries of sex workers' narrative reports. Lists of `bad punters' are collated regularly from sex worker reports and distributed by outreach projects, spreading information about violent or abusive clients who should be avoided across specific geographical areas (EUROPAP, 1999b). This initiative had not been evaluated at the time of writing, but anecdotally the London Network of Sex Work Projects reported that the approach is popular with sex workers, potentially effective and well received (Ugly Mugs Newsletter, July 2000; J. Keighley, pers. commun., 2000). We determined that further exploration with an alternative narrative-based approach had intuitive appeal.
Our decision to focus on occupational health and safety issues was driven by: an awareness of gaps in existing sex work literature reported above, a brief survey of existing information leaflets available to outreach projects (which was very focused on sexual health issues) and a key need identified by both sets of informants (sex workers and outreach workers). This need was for specific information about domination (fantasy role-playing that includes the taking and surrendering of power). It was reported anecdotally to us by outreach project workers and sex workers working in London chambers that many sex workers were choosing to enter this specialist form of sex work, but with a lack of knowledge, putting both their own and their client's health at risk.
Aims of pilot project
The broad objective was to draw on recorded sound extracts from oral history interviews with sex workers to develop a `narrative-based' peer education resource tape for sex workers and to undertake a pilot evaluation of its implementation in one pilot site. The four aims of the pilot project are listed in Figure 1.
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Pilot tape design and development
Using extracts from the OHP project, the authors edited down a 28-min health education tape (14 min per side). It contained stories and ideas about different aspects of health and safety in sex work. These were issues mentioned by those interviewed as ideas that sex workers wanted to pass on to other people doing the same job or stories of how they had learned some of the subtleties of working more safely. The authors selected extracts through consultation with three of the seven sex workers who gave the oral history material and the outreach worker collaborator.
Different extracts relating to health and safety issues about `straight' sex work were included on Side A and Side B was reserved for extracts relating directly to domination, which we restricted to corporal punishment and bondage work as these were considered the most common forms practised. Extract examples from the full transcript of the tape are included as Figure 2 to give a flavour of the range of material included.
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A full version of the original selected extracts of recordings was played to the medical personnel at the collaborating outreach project prior to editing the final cut, in order to check the medical accuracy of the information described in the extracts. We were advised not to include an extract about the effect of combining Viagra with amyl nitrate, as the medical personnel felt this would be partial since no information was to be included about other drugs that can react with Viagra. We were also advised to make it clear that the extract relating to the use of a natural sea-sponge during menstruation should include the interviewer's question: `Have you ever got a sponge stuck up inside?'. The intention was to emphasize that natural sea sponges are not risk free. The tape was edited accordingly.
We also wanted to experiment with different styles of presentation. Hence our selection of extracts was also modified by a desire to use a range of different voices on Side A (Mandy, Kate, Leila, Lolita, Lauren and Jackie) and on Side B we drew on just one person's account (Carl). The names used were aliases, usually working names, that were specified by the sex workers who gave the recordings. By choosing these individuals, although the selection was confined to sex workers working in the UK, an attempt was made to include a range of regional and national accents including those from Birmingham, Sheffield, Zimbabwe, London and Plymouth. Each person whose voice was used had already signed copyright access to the British Library with no restrictions on its use by the authors. However, through further consultation with those whose extracts were selected, two of the seven chose to have their extracts read by an actor for anonymity. In selecting the actor, we experimented with recordings by a number of friends and colleagues, and finally chose an actor who had herself worked as a sex worker's maid.
Forty copies of the tape of extracts were made and a tape box insert was prepared. This insert was designed to include an abstract image on the outside cover (so that sex workers could potentially take the tape home without others instantly knowing it contained information relating to sex work). A minimal amount of information about the tape was included on the inside cover of the tape insert (Figure 3).
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Pilot tape distribution
The tapes were initially distributed to a limited sample of sex workers via the outreach worker collaborator. She played the tape to groups of sex workers who came to the weekly drop-in. She also carried a walkman with her when visiting flats on her weekly outreach service, distributing the tape to flat-workers and offering them the chance to listen to it immediately if they wished or to keep the tape and listen to it in their own time. This distribution took place over a time limited 2-month period, from April to May 1999. This time limit was contingent on restricted funding. Tapes were also played by the authors and collaborator to other outreach project workers at the distribution site and at one other sex work project in South London during this period. For convenience this sub-sample is termed `project workers' in the following account.
Pilot evaluation
All those who heard the tape were asked to fill in a brief 12-item self-completion questionnaire (Figure 4). This was designed to be brief and succinct, mainly open-ended, and to fit onto a two-sided A4 sheet, guided by the assumption that a long and onerous questionnaire would limit return rates.
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We accepted at the outset that sex workers are a `hard to reach' population, and given the time and funding limitations of the pilot project, the pilot evaluation design would be empirically naive. Criteria for soundness in peer education evaluation have been identified to include `both an intervention and an equivalent control and comparison group, providing pre- and post- intervention data and reporting on all relevant outcomes' [(Elford et al., 2000
), p. 209]. With no substantial funding available or likely to be made available without some pilot evidence to support our hunches, and given that we were keen to respond quickly to sex workers' ideas, the evaluative design employed was brief, speculative and lacked rigour in these conventional evaluation terms. The pilot evaluation sample was small. It was estimated that over a 2-month period, the outreach worker distributing the tapes would be able to access about 40 women. In reality, this potential sample was smaller, as outreach work at the pilot site was interrupted by other emergencies. In total, 30 tapes were distributed and 22 evaluation forms were returned: 15 were completed by sex workers or by the outreach worker writing down sex workers' verbatim reports in their presence; seven were completed by project workers at the two sex work outreach project sites noted above (including four outreach workers, a nurse, a general practitioner and a student). Eight sex workers did not return questionnaires during the limited time scale of the pilot project. Re-tracking them was problematic as they did not revisit the project drop-in or receive a second outreach visit during the pilot period.
Due to the limited sample size, analysis was restricted to very basic descriptive statistics and drawing out comments in qualitative form. Together with broader developmental process issues described in this section, these were used to evaluate the pilot resource.
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Results |
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Pilot sample characteristics
There was a fairly even balance amongst the 15 sex worker respondents according to how long they had been doing sex work. Three had been working for less than 1 year, six for 1–2 years and six for 3 years or more. The majority worked in flats (n = 14), although, of these, three also worked in a sauna and one also did escort work. One respondent worked in a street setting and did escort work. One of the flat-workers noted that she no longer worked but was a land-lady for other sex workers. In terms of identified ethnic origin, three sex workers were black UK or mixed race and the remainder were white. Four sex workers were aged 31–50 years, eight were 19–30 years and one was under 18 years. Two sex worker responses were missing for age. The project workers did not specify age or ethnicity.
Process issues
Five sex workers listened to the tape in a working flat and five in the outreach project drop-in centre. Two took it home to listen to, while a further two listened to it in the car. One person listened on a walkman, but did not state the location. Five of the sex workers listened to the tape alone and the remaining 10 said they listened to the tape with other people. Of the seven who specified who they listened to the tape with, most listened with either an outreach worker, a fellow sex-worker, friend or their maid (receptionist). All the project worker respondents listened to the tape with colleagues at the project centre.
Taking project workers and sex workers together, 15 commented on the number, type and accents of the voices included on the tape. Nine people made positive comments such as:
Very varied, important as not stereotyping.
...man's voice calm, confidence-inspiring.
Liked the mix of voices.
Three gave suggestions about additional information they would have liked about the speakers, such as:
I would have been interested in [...] within which area of the sex industry they worked...if or how different types of sex work have different considerations.
The remaining three made negative comments about the voices included (all of whom were project workers), including:
Don't think they really represent majority of sex workers, projects will come across.
Too posh.
Seven sex workers and all seven project workers felt the length of the tape was `just right'. Four sex workers wished it was longer and two felt it was too long. Two sex workers did not answer this question.
Occupational health and safety information and self-esteem
The tape received a positive overall rating from all respondents, with 16 rating it as very interesting and six as quite interesting. No-one thought it was OK or boring. Some comments were:
Helpful...it reminded me of a few points. The information was very useful.
It is important to consider and be aware of a number of different potential problems.
Good—amusing. Basically peoples' horror stories.
Chance to hear other people say what I feel.
Enjoyed the fact that the anecdotes were funny. Made it easier to listen.
Could identify with others' experience.
Helpful as it has made me more wary and alert of who I let in the flat. [Respondent's emphasis].
When asked to comment on which aspects of the tape they liked best, all respondents commented. Five respondents specifically commented that the overall anecdotal quality/personal testimony nature of the extracts was their favourite feature. Others individually commented on valuing the practical advice and sensible suggestions, aspects relating to safety and vetting `dodgy punters', and telling `new girls' what they need to know.
In exploring respondents' preference for different types of information and which information was most useful, the domination side of the tape (Side B) proved most popular with 19 of the 22 respondents. A typical comment was that it was new and refreshing to hear domination practice described. Comments from four of the seven project workers indicated that the information on domination extended their own knowledge base, indicating that the sex workers were receiving information not available to them through this conventional route.
Six sex workers and four project workers listed `worst' things about the tape. Three sex workers' comments were that the tape was depressing and three that more information was needed about the whole issue of working when menstruating. Four project workers again suggested that the voices and accents represented were limited.
All respondents said they learned something new from the tape, with the exception of one sex worker who still stated that she found it interesting. Particular extracts picked out as striking a chord with some individuals included: the extract about not using two condoms, information on the dangers of using poppers (amyl nitrate), the comment about the `dark side' of prostitution and self-esteem issues, and the humorous story about the elderly client who had a heart attack.
Fifteen respondents had comments to make about information not included that would be useful to include on a future tape. The two most frequent suggestions were a need for more data about domination and more on personal feelings about being a sex worker. Other suggestions included more on: pensions and finance advice, vetting client, client safety/client drug use, dealing with complaints, police and legal matters, and the maid's (receptionist's) perspective
Impact on behaviour/lifeskills
The question about whether the information on the tape had an impact on the way respondents worked was interestingly only read as applicable to the 15 sex workers in the pilot sample. Of these, 12 said that the tape had definitely affected their working practice, making them more conscious of health and safety aspects of their work, particularly in relation to client well-being, potentially violent clients and vetting strategies, and the finer points of domination practice. Two said it had not affected their working practices. Suggesting that the `snowball' distribution through informal networks hoped for could potentially be effective, the person who now runs a working flat wrote:
[I am an] Ex-worker. Would play it to girls in my flat though.
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Discussion |
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The aim here is to pull together what we have learned from this pilot initiative as a whole, and to detail how that might inform broader experimentation with the approach developed and a clearer understanding of the challenges it raises for sex worker peer education more broadly. Again we emphasize that the pilot evaluation sample size was much smaller than we would have liked and any conclusions drawn are posited with caution.
In terms of our first aim to enhance positive changes in knowledge and awareness of occupational health and safety issues, Side B, containing information about the safe practice of domination, appeared to have the most impact. The comments suggested that the initiative was important in sharing detailed knowledge from sex workers who have specialized in the provision of domination services, who can provide information not commonly available to health professionals or to sex workers working in fairly isolated situations. The fact that project workers also reported learning from the tape suggests it may have additional value in health professional training. Hence, in comparison to outreach approaches in the UK, the tape method appeared to offer complimentary specialist knowledge.
Some interesting ideas were gleaned about other information that sex workers would like to be included on any future tapes to increase their shared knowledge and awareness. It could be conceived that these are all issues not satisfactorily covered by conventional health outreach approaches in the UK. This suggests that the tape resource could be useful in moving outside conventional outreach agendas to stimulate sex worker reports of health and safety information need. Such an idea situates this work in a context that reflects the critiques of Overs (Overs, 1997) and Cohen (Cohen, 1996) suggesting that the risks identified by health authorities as requiring attention by outreach projects may have limited relation to the real dangers experienced by sex workers. It also relates to a bigger policy issue about sex workers not often being stimulated to take ownership of the health and safety agenda or being given opportunities to directly influence policy (Alexander, 1999). Aside from fairly basic needs assessment, sex workers in England have always been (perhaps unintentionally) excluded and the tape potentially represents one small innovative way to move towards more inclusive practice.
Linking to our second aim to explore the potential impact of the tape on sex workers' self-esteem, respondents consistently commented that they particularly liked the personal testimony/anecdotal aspect of the extracts. We could hypothesize that providing embedded social information in this way could be tentatively linked to concepts of empowerment and perhaps increased self-esteem. The response to Side A (straight sex work issues) is most applicable here. This information appeared to act as a consciousness-raising tool. For the more experienced workers, these were not new stories, but captured nuanced articulation of scenarios witnessed by many but rarely openly discussed. No differences were found in relation to the length of time that each sex worker had been working in sex work, suggesting that even for experienced sex workers, new information to challenge or confirm existing work practices might be welcomed. From the comments relating to how the tape affected their working practices, the information on the tape could be interpreted as enhancing assertiveness and confidence in performing a particular behaviour (such as turning away `dodgy' clients), potentially achieving self-efficacy in relation to socially learned behaviour. Clearly further research would be required to fully explore these contentions.
The generally positive response from those whose recordings were used on the tape (not reported here) could also be construed as potentially improving self-esteem for those directly involved in designing peer education initiatives. This supports other peer education evidence relating to the beneficial effects for those involved in such collaborative ventures (Klein et al., 1994). In this sense, the initiative complimented outreach approaches that are not sex worker driven.
However, in characterizing the tape as depressing, the self-esteem of some sex worker respondents could be argued to have been decreased. This raises concern about potentially raising sex worker's anxiety levels without offering back-up counselling support (except in the provision of a helpline telephone number on the tape box). Such support would more likely be available through direct person to person peer education through outreach or peer training approaches. However, it could also suggest that, with careful distribution, the tape could stimulate discussions and action for those who are tired of their job or seeking to exit prostitution. This may particularly be true for new, inexperienced sex workers, although our pilot sample was not big enough to explore this contention. Overall, from our limited findings, the impact of listening to the tape on sex worker's self-esteem was equivocal.
Considering our third aim to explore the potential impact on sex workers' life skills, a relatively high proportion of sex worker respondents commented that the tape had an impact in changing the way they worked. However, the information available to us about quite what this behaviour change involved was incredibly limited, both by the restriction of our limited question on the subject, and by concerns about whether there are gaps between what people do and say in response to surveys undertaken in a sexualized context (Kippax et al., 1993; Hickson et al., 1996). We also failed to monitor whether workers listened to the tape more than once, potentially allowing for reinforcement through repeated listenings, or whether any behaviour changes would be sustained over time. Further evaluation of these issues with larger, controlled sample groups is needed.
Our fourth aim was to document process issues. Starting with content and design issues, the editing process and the resultant balance of extracts included was broadly judged as credible and acceptable, which may simply highlight the wider claim for peer education of the value of using language adapted to the target group (Europeer, 1998). It is interesting to note that the only three negative comments saying that the voices were unrepresentative were made by project workers, not sex workers. This might suggest that project workers tend to form stereotypical ideas about the sex workers that they work with and again supports the potential value of using the tape in educational settings for health professionals.
For some sex workers, we were aware that we had to be quite `pushy' in persuading them to listen to the tape in the first place. Once they listened, their attention was held not so much by the information itself, as by a fascination with trying to recognize the voices on the tape. Although not reported on the evaluation forms, a typical comment was: `Oh I know her. She's that blonde bird from up Finsbury Park, works in x's place'. Invariably they were wrong about the person's identity, but this raised some anxiety in us about the extent to which we had exposed those who gave the material and potentially created new hierarchies that might create local tensions and jealousies were speakers to be identified. Our taped, `anonymised' peer educators only marginally avoided the same kind of problem reported by TAMPEP of elevating their trained peer educators to high status opinion leaders (TAMPEP, 1997). Further experimentation with anonymity and the use of actors voices might be needed to fully explore this issue.
The fact that the majority of the sample said they listened to the tape with other people who were part of peer networks suggested that we achieved more listenings than we evaluated. However, like other diffusional peer education approaches (Brussa and Mongard, 1998), we found it difficult to manage or evaluate the process of cascading information spread through informal sex worker networks, or to find out whether the tapes would be lost or discarded. We became aware that there is potentially more risk with the tape methodology of information falling into the `wrong' hands of, for example, the tabloid newspapers, than there is when using outreach or peer training approaches.
However, the fixed format recording style of presentation meant that unlike peer education strategies that rely on verbal interaction with trained peer tutors, we knew that the messages on the tape would not be transformed or distorted in the `Chinese whispers' style reported by Turner and Shepherd (Turner and Shepherd, 1999). This method might also provide a cheaper and more practical alternative for initiating repeated cycles of peer education activity when working with highly mobile sex workers, which was an issue reported as problematic by TAMPEP (TAMPEP, 1997). The down side is that we realized that the ideas reported on the tape might quickly become outdated and inaccurate in themselves, and for such a programme to work on a wider scale, tapes would have to be regularly revised and updated. For example, just during the short pilot period, evidence was changing about advice that sex workers should be given about the use of natural sea-sponges when working while menstruating. In this context, recalling existing out-dated tapes for replacement would be problematic.
Some of our frustrations with this initial pilot evaluation clearly stem from the tension between limiting the length and depth of the evaluation questionnaire so that it appeared quick and easy to explain, complete and collect, and at the same time provided enough depth to sustain a thorough investigation of the findings. In order to obtain a larger evaluation sample, many more projects would clearly need to be recruited. Commitment of all outreach staff involved to the philosophy of the tape would be an essential and over-riding need to the success of a project like this. We recognize that we were lucky to be working with an outreach worker who shared our philosophy, but who was also under pressure in her work context to treat the pilot project as low priority in relation to other project concerns. Similarly, sex workers may not always be able to give priority to passing on and listening to tapes in the context of other work pressures. Distribution incentives may need to be further investigated.
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Concluding comment |
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Overall, this early experiment was dynamic and stimulating, but the pilot results are equivocal. Key strengths were that the pilot project methodology exemplified partnership and inclusion, and accessed specialist sex worker knowledge. Weaknesses related to insufficient measures of self-esteem, lifeskill changes, information spread, learning mechanisms and changes over time. Further investigation of tape distribution and recall mechanisms, anonymity, and status issues in selecting those who make recordings, and cost implications of the method would be helpful in order to fully assess to what extent the method described here can really compliment existing peer education approaches with sex workers.
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Acknowledgments |
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Our thanks go to the sex workers who recorded material and advised on tape design, particularly to Carl. Thanks also to Clare Emelius for the artwork and for coordinating the main distribution of the tape with colleagues at the Praed Street Project, St Mary's Hospital, London, who also helped check the medical validity of the material. Credit to Helen Ryan at the Health Education Authority for supporting the idea, and to Rob Perks and Jenny Verlini at the British Library National Sound Archive for supporting the OHP Project.
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References |
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Brussa, L. and Mongard, H. (1998) Some problems concerning peer education. Research for Sex Work, 1, 6–7.
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Received on August 27, 1999; accepted on August 26, 2000
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