A midterm and an endpoint survey were conducted in 2012 and 2014, respectively. Similar methods, tools, and procedures were used for both surveys. Details of the surveys have been published elsewhere [14–16].
Study population and sampling
The z test for a two-sample comparison of proportions was employed to detect a change of 10 % of sexual and healthcare-seeking behavior indicators such as consistent condom use with regular partners and utilization of VCCT services. A power of 80 % with 95 % confidence interval (CI) and design effect of 2 for compensation of cluster effect was set for the sample size calculation. As a result, the total minimum required sample size was approximately 410 women. Adjusted for incomplete data of 10 %, the final minimum sample size required for the surveys was approximately 460.
The study was conducted in Phnom Penh and Siem Reap. We excluded other provinces because the population size of FEWs under the SAHACOM was too small at the time when the midterm survey was conducted. Furthermore, the total number of FEWs in these two provinces represented more than 70 % of the total coverage of the integrated care and prevention and 100 % of the total coverage of the focused prevention. In total, 41 entertainment establishments in Phnom Penh and 13 in Siem Reap were covered by the SAHACOM with a total number of FEWs of 5,404 and 1,445, respectively exposed to the intervention.
The sample size was proportionally allocated to the size of FEWs under the SAHACOM in each province. A two-stage cluster sampling method was used to select the study samples. Communes were used as sampling units, and the number of entertainment establishments in each selected commune was decided based upon the number of FEWs in each commune. In order to be included in the study, an entertainment establishment must have at least 20 FEWs. We also considered other factors when deciding whether to include an entertainment establishment such as convenience for data collection and duration of the project implementation in the commune. The participants were then randomly selected from the entertainment establishments.
A FEW would be included in the study if she was: (1) 18 years or older; (2) Khmer speaking; (3) working for an entertainment establishment under the coverage of the SAHACOM; (4) sexually active in the past 12 months; (5) able to provide consent to participate in the study; and (6) able to present themselves on the day of the data collection. FEWs who were mentally and/or physically too sick to participate were excluded from the study. In total, 450 FEWs at midterm and 556 FEWs at endpoint were included in this analysis.
Data collection trainings and procedures
All interviewers and field supervisors were trained for two days on questionnaire and data collection methods, and one day was allocated for tool pretesting and reflection. The purpose of the training was to make sure that all research team members understood the procedures and followed the standardized guidelines in the same manner. The training covered necessary skills including interview techniques, confidentiality, questionnaire administration, and quality control. Regular review sessions with interviewers were conducted during the survey period to review progress and communicate any problems or issues occurring during the data collection. Coordination and administration were arranged by KHANA’s implementing partners. Subjects were interviewed face-to-face with an estimated time for each interview of approximately 30 min.
Questionnaire development and measurement
The questionnaire was developed using standardized tools adapted from previous studies in the same populations [17, 18], the most recent Cambodia Demographic and Health Survey , as well as from other studies in Cambodia [20–24]. The questionnaire was initially developed in English and then translated into Khmer, the national language of Cambodia. Another translator back-translated it into English to ensure that the “content and spirit” of every original item were maintained. Clear instructions and explanations were addressed to avoid any confusion during the interviews.
Before constructing the final questionnaire, a pilot study was conducted among a random sample of 20 participants to ensure that wording and contents were culturally suitable, acceptable, and clearly understandable for the study participants. We made necessary modifications based on feedback from the pilot study and comments from researchers and practitioners working in the areas of HIV and SRH in Cambodia.
Variables included socioeconomic characteristics, sexual behaviors, SRH, healthcare seeking behaviors, HIV testing, and HIV education. We collected information regarding their sexual experiences, involvement in commercial sex, and condom use behaviors when having sexual intercourse with unpaid or regular partners as well as with commercial partners. Regarding SRH, we asked about their experiences and healthcare-seeking behaviors for the most recent STI symptoms, pregnancy, induced abortion, and contraceptive use.
Participation in this study was voluntary which was made clear to the participants both before and during the consenting process. Informed consent was obtained from each participant after a detailed description of the study objectives and procedures was provided. Privacy of the respondents was strictly protected, and confidentiality was ensured by removing all personal identifiers from the survey questionnaires. The questionnaires and data collected from the respondents were kept under the responsibility of KHANA’s Research Center. The study protocol was approved by the National Ethics Committee for Health Research, Ministry of Health, Cambodia (No. 082NECHR).
Data entry and analyses
Data were coded and entered into a computerized database using Epi Data version 3 (Odense, Denmark). Double data entry was performed to minimize entry errors. Chi-square test or Fisher’s Exact test was used for categorical variables and paired Student’s t-test for continuous variables to compare socio-economic characteristics of respondents and outcome indicators at midterm and endpoint to detect changes throughout the SAHACOM lifespan. Two-sided p-values of less than 0.05 were regarded as statistically significant. We used SPSS version 20.0 (IBM Corporation, New York, USA) for all data analyses.