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Dissertation Promoting Psychosocial Health And DISSERTATION PROMOTING PSYCHOSOCIAL HEALTH AND EMPOWERMENT AMONG FEMALE SEX WORKERS IN NEPAL: A PILOT PEER EDUCATION INTERVENTION Submitted by Lauren Marie Menger Department of Psychology In partial fulfillment of the requirements For the Degree of Doctor of Philosophy Colorado State University Fort Collins, Colorado Summer 2016 Doctoral Committee: Advisor: Lorann Stallones Gwen Fisher Michelle Kaufman Elizabeth Ryan Copyright by Lauren Marie Menger 2016 All Rights Reserved ABSTRACT PROMOTING PSYCHOSOCIAL HEALTH AND EMPOWERMENT AMONG FEMALE SEX WORKERS IN NEPAL: A PILOT PEER EDUCATION INTERVENTION Across contexts, female sex workers (FSWs) may be exposed to varying degrees and combinations of risks in their work, including but not limited to long hours, poor working conditions, disease transmission, unplanned pregnancy, violence, drug and alcohol use and abuse, debt, and various forms of harassment, discrimination, and exploitation. It is likely that the risks associated with sex work are greater in developing countries where sex workers have a low and stigmatized status, minimal capacity to earn an adequate income, limited level of control regarding clients accepted and services rendered, and restricted access to sufficiently resourced health and other services and support structures. The sex industry in Nepal is synonymously referred to as the entertainment sector. Women in the entertainment sector (WES) in Nepal are vulnerable to an array of occupational risks, which compromise their psychosocial health and empowerment, in turn limiting their ability to thrive and engage in protective behaviors. The present study involved the pilot test of a peer education intervention in collaboration with a non-governmental organization (NGO) to empower and promote the psychosocial and occupational health of WES in Kathmandu, Nepal. Ten WES were trained as peer educators (PEs) and, through formal and informal teaching opportunities, reached over 140 FSWs with psychosocial health promotion messages. In addition to a detailed literature review, method, and discussion, this dissertation comprises three manuscripts. ii The first manuscript presents results from a quasi-experimental pre/post evaluation with 160 WES, including those who were (n = 96) and were not (n = 64) exposed to the PEs, to assess the impact of the program on psychosocial and occupational health and empowerment outcomes. Results indicate that WES who were exposed to the psychosocial health promotion messages of the PEs reported significantly improved psychosocial health knowledge and perceived self-efficacy, ability to access resources, happiness, and job control compared to WES who were not exposed to the PEs. The second manuscript presents results from a mixed-methods evaluation to assess the feasibility of the program and its impact on the psychosocial and occupational health and empowerment of the 10 WES trained as PEs. PEs were surveyed at baseline, immediately post intervention, after 2-months, and after 10-months to evaluate psychosocial and occupational health, empowerment, and peer education efficacy. Upon completion of the program, one-on-one exit interviews were conducted with nine of the PEs and two field staff from the partner NGO to solicit more in-depth feedback about the program. PE survey results indicate the program had a significant impact on some aspects of psychosocial health and empowerment, with positive trends on many other variables. Exit interviews revealed additional positive impacts of the program, including enhanced confidence and communication skills and increased self-awareness and self-care behaviors. Overall, the findings presented in these two manuscripts suggest peer education is both a feasible and promising means to enhance the psychosocial and occupational health and empowerment of WES in Nepal. The third manuscript details the processes implemented in this pilot study. Peer education methods have been established as a promising way to reach FSWs and other vulnerable and hard-to-reach populations with health promotion programming; however, there is scant published iii information about how such programs are designed and implemented. This lack of process information contributes to poor clarity regarding how to effectively develop and execute peer education programs and increases the propensity for repetition among failed strategies. Using this pilot program as an example, this manuscript offers an in-depth vantage point into the black box of peer education by outlining the specific steps taken while designing, implementing, and evaluating the program. While considering each phase of the project, the challenges encountered along the way as well as the effective strategies implemented to overcome them are reviewed, with a focus on offering practical tips and strategies. Conclusions and a summary of recommendations for those interested in implementing similar programs are discussed. These three manuscripts as a whole can be used to inform future interventions aiming to enhance the psychosocial and occupational well-being and empowerment of sex workers and other vulnerable and hard-to-reach working populations through peer education methods. iv ACKNOWLEDGEMENTS This project, and my journey as a graduate student, have been supported by many mentors, friends, and family members, to whom I am extremely grateful. I would like to start by extending my deepest thanks to my advisor, Lorann Stallones, who encouraged me to pursue a dissertation topic that I feel deeply passionate about, supported me to take my first trip to Nepal in the summer of 2012, and has provided me with a great deal of mentorship throughout my entire time in graduate school. I am truly grateful for your patience, kind words, thoughtful comments, compassion, and strong ethical foundation. I would also like to extend my deepest gratitude to Dr. Michelle Kaufman, who also encouraged me to pursue this project; provided support in developing my project plan, drafting my Fulbright application, and carrying out my project; and helped me connect with numerous friends, colleagues, and my partner organization, Raksha Nepal, in Nepal. Our Skype calls at various hours of the early morning and late evening (sometimes disrupted by rats in my apartment!) contributed significantly to the success of my project as well as to my mental and emotional well-being while living abroad. Your contagious energy and passion for conducting research to promote the health and well-being of women in Nepal has been the driving force behind this project. I of course have to thank Dr. Jennifer Harman for introducing us to one another in the first place. I would also like to thank Dr. Gwen Fisher, who has been an informal co-advisor to me on this project as well as many others. Since meeting you for the first time at the Work, Stress and Health conference in Los Angeles, you have been one of my greatest mentors. Your incredibly generous and compassionate mentorship style, commitment to rigor and excellence in v research and teaching, and passion for occupational health psychology are second to none. If I achieve even half of your excellence as a mentor and occupational health psychologist in my career, I will consider myself extremely lucky. These three outstanding women have also provided an incredible amount of support (and letters) throughout my 6 month job search process, for which I am forever grateful. Finally, I would also like to thank Dr. Elizabeth Ryan, for providing her support, mentorship, and guidance as a committee member and while serving on my CSU Fulbright committee. Another significant mentor I have had the pleasure of learning from, working with, and being supported by over the past six years is Dr. Silvia Sara Canetto. You have nurtured in me a great passion for conducting methodologically rigorous, international, gender-focused research and have gone above and beyond to advocate for and provide me with the opportunities, resources, and mentoring necessary to achieve a high level of expertise and excellence as an aspiring scholar. You have always made me feel as though you care about my success and well- being, both personally and professionally, and made yourself available to provide support and guidance across many of my projects. I would next like to extend my deepest gratitude to the leadership and staff of Raksha Nepal, especially Menuka Thapa, Somaya Khapung, Renu Chaulagain, Anita Subba, Rabin Malla, Iswori (Isu) Thapa, Muna Nepali, Kabita Chaulagain, and Ganu. Without their incredible support and heroic efforts, this project would not have been nearly as successful or fun. Their undying commitment to improve the situation for women working in the entertainment sector offered inspiration and energy that truly made this project come to life. I could not have asked for a more dedicated and delightful team of collaborators. vi The success of this project also would not have been possible without the support, skills, and commitment of the research assistants I had the pleasure of working with in Nepal, especially Deepashika Pahadi and Ashika Sharma. You are incredibly smart, beautiful, funny, and loving women, and I can’t express how much I enjoyed working with and getting to know you. I admire and miss you both dearly. I was also fortunate to work with a number of research assistants in the US, including Kristen Anna, Emily Holcomb, and Helen Santoro. Each of you was such a job to work with and contributed to this project more than you know. In addition to my committee members, I was fortunate (to say the least) to receive mentorship and guidance from a number of additional mentors both in and outside of Nepal. First and foremost, I cannot adequately emphasize the contribution of Karuna Kunwar. During our first meeting at the Northfield Café in Thamel, Karuna helped me to understand the importance of promoting a stronger foundation of psychosocial health and empowerment among women in the entertainment sector, which ultimately steered the direction of the project. Throughout the project, you dedicated your valuable time to provide support and training and helped me navigate numerous challenges. I would also like to thank Leslie Brown and Drs.
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