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International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 13 Issue 10, October 2024
Fully Refereed | Open Access | Double Blind Peer Reviewed Journal
www.ijsr.net
Assessing Functional Health Status and
Psychological Well-being of Sex Workers in
Parbhani, India: A Mixed-Methods Approach
Aryaman Tiwary1, Mark Kosinki2
1 Raleigh Charter High School, Raleigh, North Carolina
Corresponding Author Email: atiwary[at]raleighcharterhs.org
ORCID: 0009-0009-4513-6714
2QualityMetric, Johnston, Rhode Island
Email: mkosinski[at]qualitymetric.com
Abstract: Background: This study aimed to assess functional health, psychological well-being, and self-esteem of adult female sex
workers (FSWs) in Parbhani, India, living with or at high risk for contracting HIV/AIDS. Patient-reported outcomes (PROs) were
quantified using the Short Form 12 Health Survey Version 2 Mental Health Enhanced (SF12v2 MH Enhanced) and Rosenberg Self-
Esteem instruments. Analysis focused on identifying specific areas for interventions to improve quality of life components. Additionally,
a custom feedback questionnaire was employed to gather qualitative feedback on Setu's interventions. Method: The study targeted 84
FSWs, averaging 37 years of age, representing 9.3% of the high-risk population in Setu’s registry–a non-profit instituting HIV/AIDS
related interventions in this region for 22 years. Participants were further divided into brothel-based workers (46/84), home-based workers
(13/84), and Tamasha artistes (dancers, 25/84). Questionnaires were administered via physical prints in Hindi and Marathi by Setu-
affiliated outreach workers and scored in accordance with the developer’s algorithms. Results: From the SF12v2 MH enhanced survey,
mean (x
) Physical Component Summary (PCS) score was 45, and mean Mental Component Summary (MCS) score was 43.2. Dancers
had the lowest PCS (x
= 44), and brothel-based workers reported the lowest MCS (x
= 40.9); 57% of this brothel-based population was
identified as possessing a high risk for depression. The Rosenberg self-esteem survey revealed low self-esteem among those afflicted with
HIV/AIDS (x
= 10.33<15, n = 15), while scores for the total sample indicated average self-esteem (x
= 16.32>15, n = 84). In the feedback
survey, 80% of respondents reported an improved quality of life. High PCS and MCS scores were linked to those who utilized Setu’s
assistance to gradually transition away from the sex-trade. Conversely, those with lower scores lacked familial or peer support or often
suffered from chronic comorbidities. Conclusion: Despite Setu’s interventions engendering significant reforms in a below poverty line
community, the sex-worker population, presented as physically and mentally stunted with scores below normative levels (PCS 50 and MCS
52). Low Rosenberg scores among HIV/AIDS subjects indicate an evident stigma-burden limiting self-esteem. Additionally, brothel-based
workers are at high risk for depression. Targeted interventions–especially for brothel-based–such as counseling and medical supervision,
could improve their quality-of-life related components.
Keywords: SF12v2 MH Enhanced, Rosenberg Self-Esteem Scale, functional health, psychological well-being, and self-esteem, Female sex
workers, FSW, Physical Component Summary, PCS, Mental Component Summary, MCS, HIV/AIDS, NGO, Setu
1. Introduction
The first incident of HIV/ AIDS in India was reported in the
city of Chennai, in the year 1986 [1]. Soon the virus
transitioned into an epidemic, particularly concentrated in the
states of Maharashtra, Andhra Pradesh and Karnataka. At its
peak, national prevalence of HIV/AIDS was estimated at
0.55% in 2000, truncated to 0.32% in 2010, and further down
to 0.21% in 2021 [2].
In the year 2019, it was estimated that Mumbai’s HIV rate was
0.73% [3]. Suburban and urbanized areas in Mumbai, housing
large numbers of sex workers, were particularly hard hit.
Other towns in the state of Maharashtra with large sex worker
populations were also adversely impacted, namely the towns
of Sangli, Nagpur, and Nasik [4]. Parbhani became another
hotspot for HIV/AIDS spread when deaths were reported in
the year 2002 due to HIV/AIDS prognosis per Setu’s 2002
project report; Setu is a non-governmental organization that
has been working to combat stigma burdens, harassment, and
oppression against those in the sex trade in this area for the
past 22 years. Additionally, 15% of Parbhani’s sex worker
population presented with an STD during the same year
(ascertained by Setu in their report to Maharashtra AIDS
Control Society, MSACS). To ameliorate the escalating crisis,
MSACS sought to partner with Setu to manage disease spread.
In response, Setu conducted an initial survey to detail the
problem in Parbhani in 2002.
State of high-risk sex workers in 2002 as ascertained by
Setu surveys and interviews:
In 2002, a survey by Setu identified 500 sex workers living in
dire conditions in Parbhani. They resided in close proximity
to garbage dumps, bus stands, movie theaters, and in low-
lying flood-prone areas with poor sanitation and no access to
clean water or electricity. Along with an elevated risk for
HIV/AIDS, their living conditions increased their
susceptibility to other infectious diseases. Societal alienation
and harassment by law enforcement agencies, brothel owners,
and partners discouraged these women from seeking help and
undergoing regular HIV/AIDS testing. They were excluded
from census surveys and systematically disenfranchised due
to the absence of vital documents, including proof of
residence, birth certificates, and Aadhaar Cards (equivalent to
Social Security Numbers). This bureaucratic oversight led to
their exclusion from Below Poverty Line (BPL) entitlements,
government assistance, and educational opportunities for their
children.
Paper ID: SR24906063641
DOI: https://dx.doi.org/10.21275/SR24906063641
1
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 13 Issue 10, October 2024
Fully Refereed | Open Access | Double Blind Peer Reviewed Journal
www.ijsr.net
Following strong recommendations from the collector and the
civil surgeon, Setu was appointed to collaborate with
Maharashtra State AIDS Control Society (MSACS) to address
the HIV/AIDS crisis in Parbhani. The MSACS initiative
encompassed sex workers, migrant laborers, and truckers,
who were identified as key vectors in disease transmission.
The program’s scope was limited to promotion of condom use,
free STD testing at civil hospitals, and distribution of HIV-
related medication. Despite the presence of comorbidities
such as hypertension, diabetes, malnutrition, and diarrhea
among Key Persons (KPs were identified by MSACS and Setu
as possessing a “high-risk” for contracting HIV/ AIDS),
medication was restricted to HIV/AIDS treatment.
Setu recognized the need for a more holistic program to
improve quality of life for these women. To this end, Setu took
to upskilling women through the institution of tailoring
programs, provision of micro-loans, establishment of pre-
primary schools offering free midday meals for the children
of these FSWs, and creation of dispensaries providing free
medicines in addition to basic health check-ups.
Setu’s dedicated advocacy efforts led to all FSWs involved
being classified as living Below Poverty Line (BPL) and thus
deemed them eligible for welfare benefits. Such classification
was pivotal in enabling their access to public distribution
systems, healthcare facilities, schools, scholarship grants, free
distribution of ration cards (food stamps), pensions for
seniors, and voter ID cards. This integrated approach,
blending social welfare with health initiatives, was
pioneering. Setu’s model became a benchmark that was
adopted by MSACS across other such intervention programs.
Setu’s intervention was particularly pertinent in eliciting
community mobilization. After the institution of such reforms,
clinic attendance for HIV and other STD testing gradually
increased to almost 100%, with 3, 500 clinic attendances for
testing and physical check-ups in 2023, and condom use rose,
with 40, 000 packets provided in 2023, per Setu’s report.
Additionally, children began attending pre-primary and
primary educational centers, with close to 100% enrollment in
government-run schools.
With marked policy improvements, the objective of this study
was to quantitatively assess functional health and
psychological well-being of sex workers using standardized
patient-reported outcome (PRO) instruments, including the
SF-12v2 MH enhanced and Rosenberg self-esteem scales.
2. Methods
84 female sex workers of mean age 37 (ranging from 19 to 50
years old) were the targeted group for the PRO instruments–
the SF12v2 MH Enhanced and Rosenberg Self-Esteem Scale.
This sample size represented 9.3% of the total high-risk
population in Setu’s database. These FSWs were further
divided into three groups based on the nature of their work and
approximate presence in the total population: brothel-based
workers (46/84), home-based workers (13/84), and Tamasha
artistes (dancers, 25/84). Additionally, 15 people from this
population were HIV/AIDS positive patients.
The administration of these questionnaires was conducted by
Setu’s outreach workers over a period of three weeks via
physical prints distributed to sex workers and HIV/AIDS
patients registered under Setu’s database. The participants
were provided detailed information about the purpose and
objectives of the study including duration and risks and
informed consent to participate was obtained prior to their
inclusion in the study. The content of these surveys was
translated into Hindi and Marathi, as most of this population
lacks English literacy.
The SF12v2 MH Enhanced instrument, consisting of 15
questions, encompasses eight distinct domains: physical
functioning, role limitations due to physical health, bodily
pain, general health perceptions, vitality, social functioning,
role limitations due to emotional health, and mental health [5].
The normative benchmark for the sample population surveyed
with mean age 37 can be best estimated with an MCS score of
52 and a PCS score of 50, per the findings from a similar
Spanish population of mean age 49–in establishing a
benchmark for comparison, it is pertinent to exclude
significantly older people who tend to report poorer PCS
scores, so these normative scores serve as a conservative
benchmark [6]. The SF12v2 MH Enhanced survey is a
globally standardized PRO instrument [5].
The Rosenberg Self-esteem scale, developed in the 1960s,
captures feelings of self-worth [7]. It is a 10-item scale that
quantifies self-esteem by ascertaining both positive and
negative feelings about the self [8]. All items are answered
using a 4-point Likert scale format ranging from strongly
agree to strongly disagree, and item response values are
summed to obtain a total scale score that ranges from 0 and 30
[8]. A cut point score of 15 and below indicates low self-
esteem [8].
Additionally, a qualitative feedback survey was developed in
consultation with on-site project managers and peer educators
to determine specific successes and failures of Setu’s
intervention in Parbhani and common themes among those
with healthy SF12v2 MH enhanced and Rosenberg self-
esteem scores.
Scoring for the SF12v2 MH Enhanced survey was
accomplished using QualityMetric’ s Smart Measurement
System, PRO Insight–a professional PRO analytics software
[9]. Data were transcribed from physical surveys into an
online directory to extract site specific MCS and PCS scoring.
3. Results
The following tables summarize data obtained from the survey
respondents–84 FSWs with mean age 37 (ranging from 19 to
50 years old), including a sub-sample of HIV/AIDS patients
isolated for the Rosenberg self-esteem scale (Table 3).
Paper ID: SR24906063641
DOI: https://dx.doi.org/10.21275/SR24906063641
2
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 13 Issue 10, October 2024
Fully Refereed | Open Access | Double Blind Peer Reviewed Journal
www.ijsr.net
Table 1: Condensed summary of PCS and MCS scores obtained from the SF12v2 MH Enhanced instrument for each FSW
site and the total sample population. See Table 2 for elaboration of moderate/high bodily pain.
Number of
Respondents
Mean Mental
Component
Summary (MCS)
Mean Physical
Component
Summary (PCS)
Risk of Depression (%
respondents under MCS
of 42)
Percent of Population
suffering from mod/high
bodily pain
Brothel-based workers 46 40.9 45.1 57% 70%
Home-based workers 13 49.4 46.5 8% 38%
Tamasha artistes (dancer community)
25 44.2 44 32% 60%
Total Population
84 43.2 45 42% 62%
Table 2: Detailed PRO analytics scores obtained from the SF12v2 MH Enhanced scoring algorithm, including FSW sites and
sub-component scores. Those with moderate to high pain impacts reported bodily pain interfering either “quite a bit” or
“extremely” with physical functioning in their questionnaires. Similarly, those reporting work and activity problems indicated
that their physical condition impeded their jobs and other activities.
Brothel-based Tamasha artistes (dancers) Home-based Cumulative
Mean Physical Component Summary
45.1 44 46.5 45
Physical Functioning
42.2 42 45 42.5
Role Physical
42.2 43.4 43.8 42.8
Bodily Pain 41.5 40.8 46.6 42.1
General Health 46.8 46.2 51.3 47.3
Mean Mental Component Summary
40.9 44.2 49.4 43.2
Vitality
48.8 50.6 54.4 50.3
Social Functioning
40.1 44.1 47.3 42.4
Role Emotional 36.9 38 45.1 38.5
Mental Health 41.5 44.2 47.9 43.3
Risk of Depression 57% 32% 8% 42%
Moderate/ High Pain Impact
70% 60% 38% 62%
Work/ Activity Problems
35% 32% 23% 32%
Table 3: Rosenberg self-esteem response summary in the cumulative vulnerable sex worker population (n = 84) and
HIV/AIDS patients (n = 15).
Rosenberg Self-esteem survey All Subjects 15 HIV/ AIDS Positive Subjects only
% (Strongly Agree + Agree)
% (Strongly Agree + Agree)
On the whole, I am satisfied with myself.
70 13
2. At times I think I am no good at all. 54 100
3. I feel that I have a number of good qualities.
62 27
4. I am able to do things as well as most other people. 68 7
5. I feel I do not have much to be proud of. 58 100
6. I certainly feel useless at times.
62 93
7. I feel that I'm a person of worth, at least on an equal plane
with others. 54 0
8. I wish I could have more respect for myself.
71 93
9. All in all, I am inclined to feel that I am a failure. 39 73
10. I take a positive attitude toward myself.
86 80
Rosenberg Mean score 16.32 10.33
Table 4: Qualitative impact assessment of Setu’s support on sex workers and their families
Initiation and Current Status
% (Agree)
Entered the sex trade willingly 60%
Currently in the profession by choice
97%
Family Approval and Support
Full family support
45%
Limited family support
27.5%
No family support 27.5%
Sole Providers/ Head of household 83%
Compensation: Limited compensation from clients 69%
Enhanced
Quality of Life: Setu's Impact
Recognize Setu's role in providing financial stability
84%
Assisted Health Services: Support in regular HIV and STD testing at government hospitals 100%
Reported i
nadequate supply of free condoms
92%
Paper ID: SR24906063641
DOI: https://dx.doi.org/10.21275/SR24906063641
3
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 13 Issue 10, October 2024
Fully Refereed | Open Access | Double Blind Peer Reviewed Journal
www.ijsr.net
Increased willingness to purchase condoms for safe sex practices because of increased awareness and counseling 70%
Protection and Advocacy by Setu
Protection from police raids, harassment from brothel owners, clients, partners, family, and other threats from locals 100%
Government r
ecognition and eligibility for relief programs due to Setu's intervention
Received ration cards, voter IDs, SSNs, and bank accounts 100%
Access to most of the eligible g
overnment schemes 90%
Government Issued IDs and Certificates for family:
Mothers reporting assistance from Setu
81%
Mentoring and Guidance from Setu Volunteers
Children receiving strong mentoring
64%
Children receiving limited mentoring
25%
Impact of Setu counseling on Emotional Status and Security
Increased willingness to discuss personal health risks and seek emotional support
80%
4. Discussion
Analyzing the data presented in Table 1 and Table 2, it is
evident that the sex worker community in Parbhani as a whole
present as physically stunted within every sub-group studied.
Compared to the normative PCS of 50 for a Spanish
population of similar mean age (see Methods), the Setu FSW
community, with a mean PCS of 45, falls well below this
figure, indicating limited physical health, general health,
vitality and high body pain. Brothel-based workers and
dancers presented with particularly low PCS scores. Over
70% of brothel-based workers and 60% of dancers scored
below 40 on the PCS scale, indicating moderate/high chronic
pain and substantial physical limitations [5].
It is also pertinent to interpret these PCS scores in the context
of other HIV vulnerable populations. A population of 112
Canadians in Ontario, with Caucasian men of mean age 49 as
the majority demographic, surveyed at a clinic specializing in
HIV/AIDS care scored a mean PCS of 47.7 [10]. Though this
score is higher than that of the women in India, it is important
to note here that this population was relatively affluent and
under regular medical supervision and rehabilitation during
the course of the study; they were well-managed. Conversely,
a study conducted on 86 members of a low-income population
not under medical supervision prior to the study in
Indianapolis (Indiana, United States), again comprising a
Caucasian male majority, reported a mean PCS of 41.0 [11].
Though the lack of SF12-v2 MH enhanced surveys on
HIV/AIDS vulnerable populations prevents any conclusion as
to the condition of FSWs in Parbhani, mean PCS ranging from
44 to 46.5 in different FSW sites indicates room for
improvement in habilitation efforts while also potentially
ascribing merit to Setu’s interventions within a population in
which all members reside below India’s poverty line.
Nevertheless, it is important to note that this PCS range is one
typically seen in older adults aged 65 and above, making the
findings especially concerning [6].
Mental Component Summary scores also revealed prevalent
mental adversity in Parbhani’s HIV/AIDS vulnerable
population. Compared to the normative mean MCS of 52 for
a mean age of 37 (see Methods), the Parbhani sex worker
community scored significantly lower at 43.2 [6]. Such a score
indicates limited social functioning, psychological distress,
and a heightened risk for depression. Brothel-based workers
particularly presented with substantial mental adversity,
scoring an average of 40.9. Such a result is concerning
because MCS scores below 42 indicate a high risk for
depression, which 57% of the brothel-based workers fell
under–significantly higher than rest of India’s normative 28%
depression risk for the general population [12]. This
correlation between MCS scores lower than 42 and a high risk
for depression is derived from studies correlating an MCS of
42 with the greatest sensitivity and specificity in identifying
patients with a known diagnosis of clinical depression [13].
Interpreting this data in the context of the same HIV/AIDS
vulnerable populations alluded to above, mean MCS in the
“well-managed” Canadian (Ontario) and unmanaged low-
income Indianapolis populations were 44 and 41.9,
respectively [10]. Once again, Parbhani’s population, having
undergone several years of intervention but lacking
specialized care facilities, falls in between the two samples.
Additionally, it is important to note that in all three
populations MCS scores deviate more significantly from
normative data than PCS scores, potentially indicating that the
mental adversities associated with HIV/AIDS may not be as
targeted for rehabilitation as physical ailments are.
Per the Rosenberg data (Table 3), the larger FSW community
scored 16.32, which indicates average self-esteem. Such
outcomes can be ascribed to Setu's advocacy and holistic
interventional approach: in the qualitative feedback survey
(Table 4), more than 80% of survey respondents indicated
improved financial, physical, and emotional stability because
of Setu’s role in facilitating the procurement of vital official
documents such as Voter IDs, providing education and food
for their children, and protecting FSWs from police raids and
harassment from brothel owners and other authoritative
figures (see Table 4). However, isolating the Rosenberg data
to the 15 respondents suffering from HIV/AIDS, reveals a
mean score of 10.33, far below 15–the benchmark for low
self-esteem on a 0 to 30 scale (see Methods). This lack of self-
esteem can be attributed to factors like a lack of familial and
peer support systems, financial security, and mental
counseling among many of these women (Table 4 and
determined after post-survey follow up interviews with
consenting respondents and community educators).
Paper ID: SR24906063641
DOI: https://dx.doi.org/10.21275/SR24906063641
4
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2022): 7.942
Volume 13 Issue 10, October 2024
Fully Refereed | Open Access | Double Blind Peer Reviewed Journal
www.ijsr.net
Though the sex worker community in Parbhani is challenged
with physical, mental, and self-image adversities as
ascertained by data from the SF12v2 MH enhanced and
Rosenberg self-esteem questionnaires, remediation is possible
through further intervention. Particularly, HIV de-
stigmatization, support systems, and mental health counseling
for women with the illness have been evidenced to return
Rosenberg scores to normative levels [14]. Additionally, it is
important to mention that certain women had exceptionally
high MCS and PCS scores. These women were typically those
who used Setu’s micro-loan programs to start artisanal
businesses and engaged with self-help groups, with some even
becoming peer educators for Setu.
5. Conclusion
The sex worker population in Parbhani remains limited in both
physical condition and psychological well-being as indicated
by the SF12v2 MH enhanced survey, though the scores
obtained may be expected in the context of other HIV
vulnerable populations. Particular adversity is found in the
brothel-based community, in which 57% of respondents
presented with a high-risk for depression (significantly greater
than India’s normative 28% risk for the general population).
Additionally, 70% of respondents in this sub-group indicated
suffering from moderate to intense chronic pain in their
physical evaluations. Such extreme results demonstrate the
need for targeted interventions like expanded self-help
programs that are common among high MCS scoring
respondents in this community and regular medical
supervision and interventions that have been shown to
increase PCS in “well-managed” populations, such as the one
sampled from a specialized clinic in Ontario, Canada.
In regard to self-esteem, while the larger FSW community
does not have alarming issues with self-image as measured by
the Rosenberg self-esteem scale (reporting a mean score of
16.32), those suffering from HIV/AIDS all exhibited low self-
esteem, with a mean score of 10.33–well below the benchmark
of 15. Studies have proven a return to normative self-esteem
in HIV patients through targeted mental counseling and
HIV/AIDS awareness and education campaigns in relevant
communities is possible. Though explicit requests for
housing, child-care, and job security, mentioned in the free
response of the feedback survey, may be beyond the scope of
Setu’s interventional program in Parbhani, there is still room
for targeted interventions that can improve the quality of life
for this population, including cementing community-based
organization (CBO) culture for demographics lacking familial
support systems such as the brothel-based workers. By
expanding self-help groups, focusing on mental counseling,
and empowering women to advocate for their rights and
health, Setu can further foster sustainability and long-term
well-being in this vulnerable population.
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Paper ID: SR24906063641
DOI: https://dx.doi.org/10.21275/SR24906063641
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