Running Head: GRASSROOTS EMPOWERMENT PROJECT FOR BEER GIRLS 

 A Social Psychological, Grassroots Empowerment Pilot Project
for “Beer Girls” (Female Indirect Sex Workers) in Cambodia

Meghan McCourt
University of Guelph

A thesis submitted in completion of the requirements
for the degree of Honours Bachelor of Arts
PSYC*4880
Psychology Department
University of Guelph

Course Director: Michael Matthews
Supervisor: Ian Lubek
August 6th, 2002
Abstract

Part of a larger action research (AR) project focussing on the HIV/AIDS epidemic in Cambodia, this pilot study examines grassroots empowerment of the “beer girls” of Siem Reap.  These young women work in restaurants selling international beers to tourists and local men. Beer girls may choose to supplement their income by engaging in sexual relations with their clients, and after drinking with their clients to meet their quota may become too intoxicated to enforce condom compliance.  I examine the contextual and culture specific situation of the beer girls, the stigma and health risks (HIV/AIDS seropositivity) of sex work, and constraints on health, education and social needs through analysis of data gathered from 3 years of interviews in Cambodia.  The subsequent design, implementation and evaluation of a pyramidal peer education program is described and multi-method triangulation explored.  Post intervention interviews revealed 100% condom compliance resulting from workshop involvement.

Table of Contents

Abstract
.......................................................................................................................................2
Table of Contents
........................................................................................................................3
General Note on Research Context
............ .................................................................................5
An Introduction to the “Beer Girls”
..............................................................................................7
Sexual Tourists: Impact on the Epidemiological Equation
..........................................................10
Bridging the Epidemic: The Roles of Local Men and Married Women
........................................12
Empowerment at the Grassroots Level
......................................................................................13
Cultural Context: Khmer Specificity and Cultural Importations
...................................................15
The Negative Stigma of Sex Work
.............................................................................................17
Empowerment and Control for Beer Girls
.................................................................................19
Changes in Siem Reap: Grassroots Theory, Action Research Methodology
................................21
Peer Education: Pyramid Style
..................................................................................................23
Current Interventions in Siem Reap
............................................................................................24
Specific Research Questions for this Pilot Study
............................................................................26
Methods
....................................................................................................................................27
	Participants and Sampling
..................................................................................................
	Research and Intervention Methods
................................................................................29
		Defining the research in “AR”
.............................................................................29
		Designing the action in “AR”
..............................................................................31
	Cultural Sensitivity Translation Problems
.......................................................................32
Results
......................................................................................................................................33
	Contextually Situating the Siem Reap Beer Girls: Pre Intervention
..........................................33
	Clinical Behavioural Data

...............................................................................................37
	Post Intervention Interviews
............................................................................................40
Discussion
..................................................................................................................................41
References
.................................................................................................................................56
Appendix 1- Prostitution Questionnaire for All Women
..............................................................62
Appendix 2- Participatory Action Research Design
....................................................................66
Appendix 3- Excerpt from Transcript, Phnom Penh Beer Hall, 2000
..........................................67
Appendix 4- Beer Girl Focus Group Questions, February 2002
...........................................................68
Appendix 5- Excerpt from Beer Girl Data Chart 2000, 2001, 2002
............................................70
Appendix 6- Initial Evaluation Form for the Beer Girl Peer Educator Workshop, May 2002
..............81
Appendix 7- Post Peer Education Session Interview Questions, July 2002
..................................82
Appendix 8- Post Intervention Interview Data, July 2002
...........................................................83
Appendix 9- Steps for the initiation and maintenance of grassroots movements
..........................93
Table 1- Martial Status of 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
...............95
Table 2-  Education levels attained for 35 Indirect Sex Workers at Mondol Moi Health Centre- 
May-July,2002
...........................................................................................................................95
Table 3-  Condom use reported by 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
...................................................................................................................................96
Table 4- AIDS/STD Risk Perception for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
...........................................................................................................................96
Table 5- Knowledge of HIV/AIDS for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
...........................................................................................................................97
Table 6- Sources of Information about HIV/AIDS for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
....................................................................................................98
Acknowledgements
................................................................................................................99

“I am a post Khmer Rouge child
But was a slave
I was forced to work against my choice
My body is tortured
I am full of pain
I am not a citizen
I am not a person
You see me as a virus
I am invisible
Your eyes do not see me
You hate me
You blame me
Some of you pity me
I do not want your pity
I do not want your charity
I want my rights
Not your lies and abuse.”
- Dina Chan (Phnom Penh Times,1999, pg. 30)

A General Note on the Research Context of this Thesis.
	This thesis explores certain research questions I have been able to raise within the context of an ongoing larger multi-disciplinary, multi-cultural, multi-researcher project, sponsored in part by the Elton John AIDS Foundation.1   As such, it combines data from several sources: a) interviews including questions designed specifically for this study,  collected by myself in Cambodia (April 24- May 7, 2002); b) questions asked on my behalf by other research team members (February, 2002; July, 2002); c) analyses of  data from questionnaires administered by other team members at the local Mondol Moi Health Centre, and d) transcripts (and/or audio- and videotapes) of interviews conducted by myself and/or other research team members (2000-2002). 
	Beyond this ongoing project in Siem Reap, there is little current indigenous social science work in Cambodia to serve as background context. During the Pol Pot genocide (1974-1979), about 1/4 of Cambodia’s population was killed, and in particular, intellectuals were singled out for the “Killing Fields” by the Khmer Rouge. Some escaped to other countries; few academics and professionals have returned.  In the rebuilding of Cambodia, only a handful of local social scientists are active, so that much information about social life comes from such written sources as a) retrospective autobiographical accounts, b) overviews by international agencies (and their websites) based on statistics supplied by local government agencies, c) extrapolations from similar research conducted in other cultures, d) recent accounts by independent journalists, e) websites for international agencies and non-government organizations (NGOs) – e.g., Medecins sans Frontieres, UNAIDS, etc. ; and f) a small number of systematic studies conducted in Cambodia itself (i.e., Tarr & Aggleton, 1997). 
	 As a result, the cumulative  knowledge base for contextualizing  the questions to be asked in this thesis are a mix of these sources, rather than the usual studies from psychological and other professional scientific journals.  Wherever they intersect with the project’s field-gathered data and systematic interview results, I shall be making use of them, with a critical eye: I am aware that while “journalistic accounts”  may be illuminating and aid an understanding of social phenomena, they are not qualitatively equivalent to the systematic survey research conducted in countries with a corps of active social science researchers.

An Introduction to the “Beer Girls”
	Beer promotion sales women, more frequently known as “beer girls”, are young women who work in restaurants throughout Cambodia as a sort of entertainment hostess. They market usually only one international brand of beer, and wear a uniform readily identifying that company. While the term “beer girl” originated in the press, these  indirect sex workers (ISW) have been referred to as “beer promotional girls” for statistical purposes by government and international health agencies  such the World Health Organization (WHO).  The interview transcripts all show that within the community of Siem Reap, and amongst themselves, these ISWs are commonly referred to as “beer girls”. 2
	These women earn on average $US2.00 per night to sell a quota of beer3, and will sit and banter with male patrons throughout their 5-hour evening shift, trying to encourage the men to buy more beer – including rounds for the beer-girl herself  (Lubek, 2001a).  According to Marshal and Stecklow (2000), this is a successful marketing technique used by beer and liquor distributors in Cambodia and other parts of Southeast Asia.  It was estimated that there are between four and five thousand beer girls in Cambodia (Schiffrin, 1998).
	These young women, when propositioned by patrons, may agree to sell sex after their evening shift in order to supplement their income.  The concern is that with increased alcohol intake, condom compliance goes down.  In a 1997 Ministry of Health survey (cited by Schiffrin, 1998), only 10% of beer girls said they always used condoms, as compared with 42% of direct sex workers.  At that time, it was reported that HIV infection rates within this population was  growing.
	According to Marshal and Stecklow (2000), training and education for these women typically consists of being instructed on how to pour beer without creating foam.  Mr. Chan of Sam Miguel beer has been quoted as saying that he “trains the girls to drink beer if they don’t know how” (Marshal & Stecklow, 2000).  The girls are often told to take anti-drunkenness pills, which have no proven effect on alcohol consumption (Marshal & Stecklow, 2000).  This training does not involve safe sex education, which could prove crucial in preventing the further spread of the HIV/AIDS epidemic.
	The health of women in the sex industry, and their access to health care services are affected by legal discrimination and social stigma (Pheterson, 1989).  Wu and Grossman (2001) suggest that due to the assumption that sex workers are HIV positive, they are frequently denied access to health care and ignored by health providers in Cambodia.  This is in denial of the rights of the individual, and serves to further exacerbate the health crisis.  Accessible and affordable drugs to treat STIs and other prevalent diseases are lacking, with antibiotics unavailable to the majority of the population (Synergy, 2000; Lubek, 2001). 
	There is great diversity in the Cambodian sex industry, and Wu and Grossman (2001) emphasize the importance of recognizing that not all women involved in the sex industry were trafficked or sold into sex-work by their family.   These authors note that in poor areas, sex work offers income necessary to support oneself and one’s family which may be inaccessible by other means.  Cambodian Communities Out of Crisis (2001) estimates that on average, women in Cambodia receive one-third less pay than men with similar education and experience for comparable work.  According to Mathi (2000), not all girls want to leave sex-work ; some get used to it and others cannot adjust to other jobs.   There is variation between the different types of sex work in terms of the amount of income generally earned, as well as the amount of freedom experienced (Wu & Grossman, 2001).  The great variation between direct and indirect sex workers leads to the necessity for interventions which take these diversities into account. While brothel workers generally stay in place,  have fixed addresses and attend the same clinic, indirect sex workers and beer girls are more mobile, move between restaurants, some switch companies, and some are moved by the beer distributors to other cities. It is therefore perhaps more difficult to reach indirect sex workers with any ongoing educational interventions: in fact, after some condom compliance programs were put in place, there has been a decrease in HIV prevalence reported among the DSWs between 1998 and 2000, while beer girls showed no change in infection rates (National HIV Sentinel Surveillance [HSS], 2000, as quoted by Lubek, 2001c). With  reported  condom compliance increasing in the direct sex worker population, it has been suggested that indirect sex workers have the potential to lead toward a new surge of infections (Synergy, 2000). 
	According to Synergy (2000), the Cambodian AIDS epidemic is linked to gender roles and the low socio-economic and social status of women.  Literacy among the adult female population is estimated at 57%.  The career options of the women of Cambodia are extremely limited due to their low levels of literacy and education, with even jobs as hotel chambermaids requiring literacy and knowledge of another language (Lubek & Wong, 2001).
	A study cited by the Agence France Presse (October, 2001) estimates that 169,000 of the 12 million people in the Cambodian population aged 15-49 are HIV positive.  This is a decline from 1999's estimate of 184,000 and 1997's estimate of 210,000.  While this may seem like an important decrease, Reuters (2001) reported that more people are dying from HIV/AIDS than are becoming infected, which can explain the overall infection rate dropping. The number of AIDS deaths reported in 2000 was 533, while the actual death rate has been estimated at 15,000 (Agence France Presse, October 2001). Within official channels, the number of persons living with HIV/AIDS is varyling reported, as the estimates are calculated using different epidemiological prediction equations, each based upon either annual surveillance group samplings (for the HSS annual surveys) and/or voluntary, walk-in anonymous free-testing samples (CDAG). These estimates may vary from 170,000- 270,00 nationally, and from about 7,000 to 10,000 for Siem Reap (in 2000).  Some have suggested that the sheer hopelessness created by the epidemic in Cambodia is reflected in the rising numbers of suicides among young HIV positive individuals; police have estimated that 105 people under the age of 25 killed themselves in the year 2001 (Meixner & Kola, 2001 .	

Sexual Tourists: Impact on the Epidemiological Equation
	According to Mydans (2001), Cambodia is a “poor candidate” for a safe sex campaign, as it is an underdeveloped, poorly educated country with poverty fuelling it’s flourishing sex industry.  Pierre Legros, regional coordinator of NGO AFESIP (as cited in Lequicia, 2001), expresses the view that the risky behaviour observed in Cambodia has roots in suppression and repression which occurred during the Khmer Rouge period in the 1970s.  Lubek and Wong (2001b) propose that the genocide and uprooting experienced as a result of the Pol Pot regime touched almost every family nationwide. This has contributed to the traumatizing break-up of traditional family and social life – including marriage, courtship and gender role expectations.  .  
	The arrival of the UN (UNTAC) troops occured after both the genocide period (1975-1979)  and the subsequent “economic libertization” (1979-1990), and this influx of “wealthy foreigners” contributed to the resurgence of prostitution in Cambodia after 1990 (Hughes, 2000).  According to Hughes (2000), once the UNTAC troops had withdrawn from Southeast Asia, the pimps and other supporters of the sex trade needed new markets for the women and girls.  Subsequently, they began to advertise their services to Japan and Germany, and with the development of the tourist industry used the sex industry as an attraction for foreign men (Hughes, 2000).  About 2/3 of visitors to Cambodia are men.  An estimated 22% of visitors to Cambodia are sex tourists (Straits Times, 2001).  More than 466,000 tourists arrived in Cambodia in 2000, which represents a 27% increase over 1999.   According to Gray (2000), more than 70% of the children surveyed around the Angkor Wat temples said that they had been approached by tourists for sex. In recounting the AIDS crisis faced by Thailand, Erni (1997) suggests that conflict has existed between promoting tourism (and sexual tourism) and the need to deal with the consequent crisis involving HIV/AIDS, a sexually transmitted disease. This dilemna has now crossed the border into Cambodia. 
	 Pilisuk, McAllister, and Rothman (1996, p. 16) suggest that global trends may“exploit people and habitats far beyond the reach of even the best local efforts”, and the prevalence of sexual tourism throughout southeastern Asia (along with the marketing of international products such as beer, wine and spirits) contribute to the context of social power disparities which affect the beer girl target group.   While there is increasing “global”  demand from sexual tourists, any locally -sensitive intervention focussed on increasing workplace safety and/or decreasing the number of women entering the sex trade each year, may not be complete unless it also addresses the issue of sexual tourism and consequent recruitment and trafficking of women – both  from rural Cambodia and from other countries.

Bridging the Epidemic: The Roles of Local Men and Married Women
	Attention to the rising rates of HIV/AIDS among married men and their wives had been obscured by the focus previously residing on prostitutes and single men (Erni, 1997).  In 2000, 15% of married men and 21% of single men surveyed had engaged in sexual relations with prostitutes (Cambodian Communities out of Crisis, 2001).  Approximately 10,000-20,000 men buy sex in Cambodia every day (Liquicia, 2001).  These men return home from their party-nights and have sex with their wives without condoms.  Because of this risk, the division between the sex workers and the wives needs to be addressed.  The strength of both groups of women to insist on condom use is of crucial importance to the 100% condom compliance necessary to halt the epidemic (Pheterson, 1989).
	According to MAP (2001), national averages are not meaningful in the context of the Southeastern Asian AIDS epidemic, as they do not take into consideration the uneven geographic spread of HIV.  It is proposed that this is the case for two main reasons: firstly, epidemics begin as localized outbreaks before diffusing into the wider areas of the country; secondly, when the epidemic is concentrated within specific risk-groups, it is misleading to use prevalency in the general population as an indication of severity.  For example, the rates of HIV infection among pregnant women are frequently used as an indicator of the prevalency in the entire population (MAP, 2001).  The national average of infection among pregnant women is 1.9%, yet data obtained in Siem Reap during the first 6 months of 2001 has shown an infection average of 11.2%.  This illustrates the severity of the outbreak within Siem Reap, and how this can be missed by focussing only on national statistics, with little concern given to local situations. Cambodia is undergoing rural-urban population migrations, and Siem Reap, in the midst of a tourism-fanned economic boom, is also witnessing the large numbers of young people who have been forced by rural poverty to leave home in search of opportunities for higher-income in urban centres (Tarr & Aggleton, 1999).
	While there are a number of NGOs currently involved in the HIV/AIDS crisis of Cambodia, there is a lack of shared knowledge about the nature of their findings and projects.  Each seems to be focussing on a different aspect of the puzzle, and is often protective of their own data and resources, to ensure their own continuation.  This division keeps the puzzle from being viewed as a whole; those seeking information and/or treatment may have to attend several different locales and projects in order to have their needs addressed by the NGOs and government agencies. 4 Additional solutions from within the community and accessible to the community may be needed. 

Empowerment at the Grassroots Level 
	What can beer girls (and people in general) do to insure their safety in the face of the HIV/AIDS epidemic, given that their workplace puts them daily at risk for additional sexual contacts and potential virus transmission  The current project focusses on empowerment through education within the beer girl community.  Participation is regarded by the empowerment approach as a dynamic and unpredictable process, rather than as an end to itself (Asthanan & Oostvogels, 1996). Going beyond the ideas of  NSWEP (2001) , I might suggest  that there is no ideal picture of the future, but that this picture can only be shaped as it emerges from a shared group consensus, the (social) movement,  or local community discussions.  This lack of absolute direction for the target group of beer girls at risk for HIV/AIDS is further complicated by the diverse impediments faced by individual sex workers.  Asthanan and Oostvogels (1996) argue that individual vulnerability to AIDS is increased by a number of complex and interrelated factors, including: poverty, lack of education and access to information, poor self-esteem, poor health and nutrition, low social status and a lack of sexual autonomy.  According to these authors, these factors require a comprehensive and integrative approach which focuses as well on the broader contextual and  development issues of empowerment.
	WHO (2001) divides intervention for the prevention of AIDS into two types: short term and long term.  Short term interventions, also known as “risk-reduction” interventions, focus on consistent use of condoms between both commercial and personal sex partners.  Long term interventions focus on the reduction, modification or elimination of high-risk behaviours.  In these terms, the current projects of Lubek and Wong (2001) seek to undertake a short-term intervention of risk-reduction, with the intention of moving the project forward into a long-term project focussed on empowerment through education.  As such, this work involves a number of elements:
a) forming a grassroots NGO
b) multi-method triangulation as part of an action research methodology
c) an HIV prevention program
d) creating an intervention including peer education workshops and 
e) attempting to evaluate these interventions
Throughout each element of the project, materials and theories are migrated from other cultures to Cambodia where appropriate.  An overview of the reasoning behind the design of the study can be gleaned from reviewing the cultural context in which the project is set, the theories of the negative stigma of sex work, grassroots methodology, and peer education.

Cultural Context: Khmer Specificity and Cultural Importations
	Within the Khmer5 culture, the discourses of young men and young women regarding sexuality and the consequences therein are of great contradiction.  According to Tarr and Aggleton (1997), premarital sex for young men is not only condoned, but encouraged: men at marriage are expected to be experienced, but young women must be virgins.  Trips to local prostitutes and “bar girls” frequently occur as a social activity, and as such may be seen as part of a peer socializing activity.  According to Wu and Grossman (2001), this pattern creates the opportunity for substantial epidemic within the sex workers and their male clients.
	It is with the sex workers that the men are to “experiment” and try different positions and techniques.  By contrast, female exploration of their sexuality is taboo.  Young women who lose their virginity are seen as being naive, and cast negative attention on the family from the surrounding community.  Tarr and Aggleton (1997) reported that almost all of the young people they interviewed for their study regarded “bombak muk muot kruasar” (face of the family) and “vong trorkaul poch ambou” (taking care of the family reputation) within Cambodian culture as important status considerations.  According to social standards stemming from these conflictual expectations for men and women, beer girls are thus considered to be unmarriagable and may be seen as outcasts within their community.
	Beyond the conflicting social mores regarding sexuality, other cultural factors play a large role in the social positioning of beer girls, including few opportunities for education or occupational diversity.  Tarr and Aggleton (1997) describe cultural attitudes toward alcohol consumption as one of glorification.  Alcohol consumption is seen as a symbol of high status, and risk-related behaviour in the sexual context has been blamed on excessive alcohol use.  Condom use is significantly affected by alcohol consumption, with a negative correlation connecting condom use with alcohol intake.

	In light of the complex nature of the epidemic in Siem Reap, a culturally-appropriate intervention approach must be designed which addresses the individual, community and social aspects of the epidemic.  Cross cultural difficulties due to language and cultural barriers must be taken into account, as it is important to develop an approach which is culturally sensitive to  the educational level of the target group (Asthanan & Oostvogels, 1996).  Asthanan and Oostvogels (1996) warn of the difficulties of avoiding ethnocentricity when transporting research to another culture.  The Sex Worker’s Manifesto (NSWEP. 1997, p.2) suggested that “sexuality and the lives of sex workers are intrinsically enmeshed in the social structure we live within and dominant ideology which shapes our values”.   In Cambodia, much of the stigma and social positioning of the beer girls is based on the specificities of  Khmer culture, which may not immediately be apparent through a North-American value lens. For any educational intervention, then, sensitivity is required when importing materials and methods from elsewhere, as will be discussed below in the methods section. 

The Negative Stigma of Sex Work  
	Miller and Kaiser (2001) define the core feature of stigma as the possession by the stigmatized individual of an attribute which within a particular context leads to the imposition on the individual of a devalued social identity.  By affecting access to education and employment opportunities, prejudice can increase environmental demands on the stigmatized individual. Miller and Kaiser (2001) hypothesize that some stigmatized attributes are so powerful that they become part of the individual’s “master status”, and thus become the identifying or core attribute of the individual.  Miller and Kaiser (2001) subsequently conceptualize prejudice and discrimination as major stressors in the lives of stigmatized individuals.  The value of social support is explored by Miller and Kaiser (2001), as they hypothesize that this  may distract an individual from a stressful event, provide an avenue for them to express their emotions, and help the individual to redefine the event or help the individual to solve their problems. 
	“Whore stigma”, the negative stigma associated with prostitution, is based on the idea that women who earn money through sex are defined as having sold their honour, and thus have spoiled their identity (Pheterson, 1996).  Their stigma can be seen as “a mark of shame or disease on an unchaste female slave or criminal” (Pheterson, 1996, p.65).  In The Prostitution Prism, Gail Pheterson (1996) contends that with the removal of the whore stigma from the sexual economic exchange, the concept of “prostitution” evaporates. She analyses the continuum of sexual economic exchange which divides prostitution from sexual relations in exchange for resources within marital and dating relationships and points to the power differential which exists between men and women which is reinforced within sexual exchanges.

	The divide between men and women is further exacerbated by the widespread sexual double standard, illustrated clearly in Pheterson’s quote of a Cambodian proverb: “A man is a diamond and a woman is a piece of cotton; when they fall in the mud, the diamond can be washed clean, but the cotton remains dirty forever.” (pg. 11)6.  
	Pheterson discusses the great diversity of women who work in the sex trade- be it based in ethnicity, family circumstance, geographic location, personal history, reasons for entering the trade, and economic circumstance (Appendix 1).   This notion is evident in the small yet exceptionally diverse sample of women who were interviewed in Phnom Penh and Siem Reap. She also notes terminological differences concerning women for whom the occupation is forced, and those who choose to enter it.7  Perhaps then, interventions must be designed in order to offer training alternatives for those who wish to leave the occupation, and with skills and knowledge in order to preserve the health and safety of those who choose to remain therein.
	While much of the stigma and harmful health effects of prostitution are faced by beer girls, there exists a basic difference between these indirect sex workers and the direct sex workers.  These indirect sex workers are supplementing their beer-selling income  with sex.  They choose at the end of the evening to go with their client– or not to go, As such, they face a different series of issues and stigma stemming from the choices they make.  
	Discussing another sort of indirect sex work, Roni and Ellis (1989), in their study of North American “lap dancers”, suggest that this group’s relative  empowerment stems from education about job-related techniques, health, and life skills. In their “study of exchanges between those who are differentially empowered” (Roni & Ellis, 1989, p. 424), the idea of control is reinforced frequently; the lap dancers develop skills to manipulate the men in extending the amounts of financial compensation for the “permitted” sexual activities. The successful lap dancer understands,  and coordinates with, the specific strategies of the men:  

“A table dancer must be a charming and sexy companion, keep the customer interested and turned on, make him feel special, and be a good reader of character and a successful salesperson; at the same time, she must deal with her own negative feelings about the customer or about herself, negotiate limits, and then keep him under control to avoid getting fired by management.”-  Roni and Ellis, 1989, p.408			

A  process of negotiation involving  strategy and control, occurs in a series of  exchanges as both the dancer and customer attempt to determine what they are willing to give and what may be procured from the other in the exchange (Roni & Ellis, 1989).

Empowerment and Control for Beer Girls
	Can some of these control, empowerment techniques be applicable to the beer girls of Siem Reap? How could they be taught?  It would be important to know what understanding the beer girls already have of their workplace, their clients, and what control and manipulation techniques they already possess and exercise.  It would also be important not to ignore the vulnerabilities and possible exploitations of the beer girls. But given their employment situations, can additional  techniques of  empowerment  be offered for those beer girls who have selected this career path as a legitimate money making opportunity? To what extent can they, through negotiation,  gain control  concerning the health and safety of the exchange, as well as the financial return?
	According to Labonte:

“empowerment means to increase one’s capacity to define, analyse, and act upon one’s problems.  Empower is a reflexive verb: groups and individuals can only empower themselves.”  (1989, as cited by Pilisuk et al., 1996, p. 18)

Thus, empowerment, as a psychological concept, refers to an individual’s sense of self and group efficacy (Wittig, 1996).  Wittig (1996) further defines empowerment also in terms of relations between individuals, groups, and between individuals and groups.  This concept can also be applied to sociopolitical differentiations among cultures, ethnicities and nations (Wittig, 1996).
	For the purposes of the current project, the term empowerment will be used to refer to an increasing of an individual’s sense of self and control,  and their group’s efficacy and collective identity.  One goal of this proposal, then, is to help determine what the beer girl’s group determines that they require in order to increase their individual feelings of self-esteem and efficacy, and what would be required in order to develop a sense of collective identity and group-efficacy.  According to Pilisuk et al. (1996), once a sense of collective self-efficacy emerges, goals which had previously seemed out of reach of the individual can be thought of as being within the grasp of the group.
	Three levels of empowerment related to AIDS intervention projects have been defined by Asthanan and Oostvogels (1996): personal, community and societal.  Personal empowerment refers to “a vulnerable individual [who] has not only the knowledge and means, but the motivation and power to implement and sustain behavioural change” (Asthanan & Oostvogels, 1996, p.135).  Through this level of empowerment, individuals experience an enhancement of their self-esteem and self-respect, followed by increased confidence to demand control over their sexual autonomy and practices.  Asthanan and Oostvogels (1996) posit the goal of personal empowerment for sex workers is to learn to respect themselves and demand this respect from others, instead of internalizing societal stereotypes.
	At the community intervention level, empowerment focuses on the strength in numbers to withstand structures of oppression and mobilize for change (Asthanan & Oostvogels, 1996).  The first step identified in this process by Asthanan and Oostvogels (1996), is that of conscientization.  This sharing of experiences is posited to contribute to greater consciousness and improved solidarity. 8
	The third level of empowerment centres on change at the societal level, and according to Asthanan and Oostvogels (1996) the  importance of this is reflected by the inclusion of the social, economic and political context of AIDS in grassroots organizations.  Traditionally, programs targeted at lowering the rates of HIV transmission have focussed on change at the individual level.  This focus ignores the role played in transmission by social, political, and economic institutions.  An example of this type of empowerment project would be that of a mass media educational campaign designed to challenge entrenched stereotypes and structures of sexism.

Changes in Siem Reap: Grassroots Theory, Action Research Methodology

“Scattered through the First World media’s sporadic coverage of Asian AIDS are images of and obligatory references to the Asian society and the cultural traits of the Asian people: they are poor, underdeveloped, reserved and custom bound, complacent, superstitious, and war-stricken.”            	   -  Erni, 1997, p. 76

	The grassroots approach to social psychology takes into account individual, interpersonal, collective, and cultural changes that are likely to occur when local groups organize for social action (Wittig, 1996).  According to Wittig (1996), the primary goal of grassroots social psychology is to promote a change in the power relations which exist within a particular area.  Instead of focussing on the targeted group as being in need of rescue, these individuals are instead seen as social actors who are active in their identity and have potential for self-determination in their need for change.

“Action research (e.g., Lewin, 1946) is particularly useful for studying such migrations across the divide between ‘ordinary’ and ‘expert’ knowledge in social movements, because it eschews the traditional expert knowledge model and replaces it with a model of reciprocal knowledge between the researcher and those for and with whom the research is done.” 		- Wittig, 1996, p. 6

 This power-sharing approach seeks to make research more relevant in the correction of oppressive societal relations (Chataway, 1997).  According to Wittig (1996), this migration across the boundaries of expert and ordinary knowledge has three main advantages: a researcher who is engaged in a collaborative effort is in a better position to understand the processes accompanying social change, collective identity formation, and empowerment; when participants with diverse perspectives bring their knowledge together the validity of the research is likely to be improved; and when research incorporates the values and insights of the individuals from whom it is intended, it is more likely to be used. Thus traditional styles of “top-down” research cannot be involved in the development of empowerment within a target group; rather, a grassroots “bottom-up” approach is needed – - “for us, by us”.  	
	The implementation of integrated community-based strategies which involve support groups and peer educators has been advocated by the World Health Organization’s Global Program on AIDS (Asthanan and Oostvogels, 1996).  These programs seek to tackle the epidemic and the behaviours putting individuals at risk by attending to the wider social, economic and cultural factors. This in turn requires a  commitment to active empowerment at the local level (Asthanan & Oostvogels, 1996).
	One focus of the current project is in fact (beer girl) empowerment at the personal level; however, since personal, community and social levels of empowerment are interrelated, any intervention targeting one aspect of empowerment must take into account these inter-connections .The utilization of a “bottom-up” grassroots AR approach will permit not just measurement over time , but also considers multiple levels of analysis (Perkins, Brown, & Taylor, 1996).

Peer Education: Pyramid style
	Grassroots participation and utilization of peer education in health promotion programmes are postulated by Campbell and Mzaidume (2001) as resulting from a paradigm shift within health promotion away from traditional health education towards a community development approach.  The effectiveness of this new paradigm approach to health promotion with sex workers has been propounded in recent research dealing with peer education projects in many culturally diverse settings.  Such cross-cultural evidence of the success of peer education programs with sex workers is provided by Asthanan and Oostvogels (1996), Walden et al (1999), Campbell and Mzaidume (2001; 2002), and Ford et al (2000).  In these projects, a wide variety of materials were adapted for use with the target group in each of the respective cultures, with evaluation of the projects occurring through both qualitative and quantitative analyses.
	In evaluating  peer education,  Asthanan and Oostvogels (1996) list its strengths:  i) enabling of access to be gained to targeted groups who would be otherwise difficult to reach due to their marginalization and stigmatization; ii) eliciting cooperation from individuals who might otherwise be suspicious of “top-down” involvement through the use of individuals who face similar risks and share common experiences; and, iii) being able to represent the target group in voicing group concerns.  This “bottom-up” design is central to grassroots AR where the group for which the research is targeted is involved in designing research questions, strategies for investigation, interpretation of results, and the development and implementation of recommendations (Wittig, 1996).
	According to Rickard and Growney (2001), projects which train sex workers to work as peer educators are known as diffusional peer education projects.  The current project utilizes a diffusional peer education design, but more specifically employs a pyramid training strategy.  Through this methodology, the first group of teachers are trained by project coordinators with the materials and strategies designed for the group, and this new group of teachers go out into the community teaching their peers and training new teachers.  This cycle continues indefinitely, as the levels of teaching spread throughout the community.

Current Interventions in Siem Reap
	In reviewing the relevant information of the cultural context of Siem Reap, the negative stigma of sex work, empowerment, grassroots perspective on action research methodology, and peer education, some challenges could be seen because of the complexities of the beer girls’ current situation, and the challenges of finding/creating appropriate empowerment techniques.  In a recursive, Lewinian AR design, the theory-generated pieces of the data-gathering(reconnaisance)  and intervention(actions) puzzle, must find their place amongst the ongoing community prioritized project stages (cf. Lubek and Wong, 2001).
	From an initial set of interviews carried out in Siem Reap and Phnom Penh during 1999, and 2000, Lubek (2001) raised  questions related to risk-taking within the Siem Reap community involving, among others, alcohol overuse and risky, unprotected sex. When fed back to community members, their reactions, feedback and re-prioritizations  led Lubek (2001) to begin to design a small action research program for  community empowerment, especially for those most at risk for HIV/AIDS. In trying to adapt methodology from other Asian settings,  Lubek & Wong (2001) considered the cultural and gendered traditions affecting infection patterns, before designing  a pilot study/focus group study to create culturally-appropriate interventions.
	In a feedback and reassessment cycle of the AR model outlined by Chataway (1997, see Appendix 2), Lubek and Wong (2001) then proposed a multi-sectoral intervention.  This proposed intervention includes:
 1) 100% condom compliance peer-education programme, involving “behavioural change strategies” materials (Khmer comic books and audio-cassettes);
 2) proposed literacy and language education upgrade of the 400 beer girls in Siem Reap by NGOs, hotels and the international beer companies; 
	 3) locally and internationally improving communication, co-operation and networking;  
4) increasing data collection and diagnostic capacity of HIV/AIDS, reduction of opportunistic infection rates; 
	 5) co-ordination of an industry supported one-stop “wellness” clinic9.  
This proposal took into account the information gathered in previous action-research cycles; it focuses not only on the individual, but also the community and society.
	Utilization of peer educators plays an integral role in the needs assessment stage of an AR project, as their ability to represent the target group enables researchers to develop program ideas which respond to felt needs, and are appropriate and acceptable (Asthanan & Oostvogels, 1996).  Further, as noted previously in discussion of grassroots methodology, peer education enables researchers to augment educational strategies in such a fashion as to appeal to the target group, as peer educators face similar risks and share common experiences with the target group (Wittig, 1996).  In the focus group sessions held by Lubek and Wong during February of 2001, a sample of 15 local beer girls were interviewed in order to ascertain their felt needs and to identify those among them who would make effectual peer educators.   In order to design an effective 100% condom compliance program, Lubek and Wong (2001) used the feedback of these beer girl focus groups in order to culturally adapt the strategies and materials which had proved effective with Singapore sex workers.
	Lubek and Wong  (2001) advocate the use of a peer education system in the promotion of strategies for the successful persuasion, by women, of their men to change their behaviour to “100% condom use”.  Potential  peer educators were selected, in part, on the basis of the February 2001 focus groups and the experience and outlooks they expressed; they also nominated other potential “teachers”.   After workshop training in May, 2002 with further refined materials, the  peer educators and their supervisor will then be delegated to monitor any further refinements needed to the educational materials, and to also monitor the effectiveness of the strategies in the targeted groups in reducing or eliminating their health risks, as part of the empowerment process.

Specific Research Questions for this Pilot Study
	With the complex social and cultural context of the beer girls in mind, a number of research questions were developed in order to ascertain:

1) demographics of the beer girls for the peer education workshop 
2) what are the specific risky behaviours and/or “bridging” they currently engage in?

3) what are their degrees of knowledge about HIV/AIDS
4) what are their behaviour patterns related to safe sex before versus after the intervention?
5) were the processes of the workshop positively evaluated?

The data gathered through this constantly evolving AR project will be used to create a collective portrait of the beer girls and their risk positioning before, during and after an intervention involving a pyramidal peer education workshop.

Methods
Participants and Sampling
	The pre-intervention (baseline) context can be described through an analysis of the data obtained in several waves of interviews and focus groups.  A total of 54 tape segments were transcribed representing interviews with the women who agreed to participate in the current AR project in Siem Reap in 2000, 2001, and 2002 (see Appendix 3).   One beer girl was interviewed in 2000, 15 women attended two focus group sessions in March of 2001, and in the 2002 focus group, 16 women participated in the session (4 of whom had also participated in 2001).  Beer restaurant interviews added additional tapes in 2001, in May of 2002, and again in July of 2002 (7 of which specifically served as the post-intervention sample). 10
 	Several constraints may mean that this sample of 54 interview segments is not wholly representative of the population of 150 beer girls in Siem Reap, estimated at 150 in 20002:  a) there were repeat interviews with some individuals, b) the population is not stable in that many beer girls move frequently to other cities, often being sent by the beer distributor so as to “ensure fresh faces” in the local restaurants, and c) they were selected according to shifting criteria. 11

	 Much of the information gathered in the 2000 interviews with citizens, doctors and just one beer girl was both idiosyncratic– personal autobiography, as well as soliciting narrative about their community and the health crisis they and their neighbours were experiencing.  The data obtained during the 2001 and 2002 focus groups were targeted at beer girls, whose high HIV prevalence rate required urgent intervention.  During these focus groups a more systematic attempt was made to ask specific questions arising jointly from the questions designed for this honours thesis (2002) as well as the related on-going projects of the other members of the AR project (see Appendix 4).
	Although the AR approach dictated a constantly dynamic shifting of the project’s goals and methods, the 54 collected interview segments may nonetheless present a systematic (or at least “quasi-systematic” ) collective portrait of the beer girls of Siem Reap, especially when contrasted to reports published in journalistic accounts of the epidemic situation. 0
	In a complementary study, Wong et al (in press) are gathering systematic behavioural data at the Mondol Moi Health Center in Siem Reap with samples of direct sex workers, married women and indirect sex workers, including beer girls.  Preliminary analyses of the first sample (collected May to July 2002) of data included 35 indirect sex workers (11 indicated they were beer girls, and 24 were ISWs from “other” entertainment venues.13  They are included here, both for comparative purposes and to seek behavioural explanations  about sexual practices which could be asked in a medical clinic setting but which were too sensitive to ask in the focus group and public interview settings.  This Mondol Moi survey data, in comparison with out AR data, will be labelled as “MM” throughout.

Research and Intervention Methods
	Defining the research in “AR”.
	Outside of the annual HIV/AIDS  Sentinel Surveys and Behavioural Sentinel Surveys , Cambodian beer girls have not as yet been the focus of any systematic, in depth research study. As such, there  were no baseline measures available when we started, nor was there any local data to guide the  design and evaluation of any peer-educator  intervention. Multi-method triangulation, useful  for judging the validity of the design, methods and results of various AR field studies (Koelen, Vaandrager & Colomer, 2001), proved an important tool,  in that this also provided recursive feedback loops allowing for adjustment and fine-tuning of the methods and materials as the study progressed.  The use of more than one approach to answer the same question,-- using multiple sources, multiple methods and multiple investigators-- allows for a proposition to be  cross checked and its information confirmed by more than one method; this may  subsequently reduce uncertainty of its interpretation (Koelen, Vaandrager & Colomer, 2001).  This combination of qualitative and quantitative sources may both help assess the consistency in results while also providing powerful evidence of success and insight into the process of change within the population of interest (Koelen, Vaandrager & Colomer, 2001).
	The methods of data collection included: a series of focus groups and on-site interviews in the beer restaurants in 2001 and 2002, offering  both qualitative and quantitative elements. As well, a clinical behavioural questionnaire was completed in the Mondol Moi clinic (May-July,  2002), and a series of post- workshop (intervention)  evaluations (May, 2002) and interviews (July, 2002) collected.  These sources of data were used in various combinations in assessing the needs of this target population and in  the design of the pilot intervention.
	The information gathered during the interviews in beer restaurants and focus groups was placed into a series of tables and grouped according to theme (Appendix 5).  Where possible, this information was used in a quantitative fashion to create a collective demographic portrait of the beer girls of Siem Reap. Other idiographic elements were extracted from the interviews creating a rich portrait of the context in which the behaviour of concern (condom nonadherence) and subsequent risk-taking and endangerment of this group has occurred.  It was not always possible to gather systematic data in some of the interview contexts..Workplace interviews were interrupted when customers arrived. 14.  And in true AR style, issues brought up by the women during the interviews often became the focus of the conversation, instead of the questions designed by the interviewer.  Put together, the information from the focus groups and beer restaurant interviews was used to create a general baseline or contextual basis for the design of the peer education intervention, and included demographical and occupational information, perception and effects of stigma, and expressed social needs of the beer girl group.
	The clinical behavioural questionnaire was completed by a random sample of 35 indirect sex workers attending the Mondol Moi health centre in Siem Reap between  May-July of 2002 (Wong, Lubek and Chhit, 2001).  These women were interviewed by a trained medical assistant, using a structured bilingual questionnaire.  The questions delved into the women’s reported sexual behaviour, condom use and knowledge of STDs.   The systematic data provided by this questionnaire was used as a baseline against which to compare the pre and post-intervention behaviours of the target group.(in 2001, 140 similar questionnaires were gathered from Direct Sex Workers, and 90 from married women.15)  This questionnaire was designed to look into the behaviour of condom use as a process which involves negotiation,  and also compares condom use between clients and non-paying partners, a previously established issue of concern within sex workers in Siem Reap (Lubek, Wong, Sarath & Chhit, 2001).  The data obtained from the questionnaires was analysed in terms of frequency of reported behaviours, as well as correlations between the behaviours and the reasons for the behaviours indicated by the women.16

	Designing the action in “AR”.
	Capacity building refers to the enhancement of the enthusiasm and competency of the target group (Pilisuk et. al, 1996).  This capacity building is dependent on psychological resources which are related to empowerment.  This would suggest that through education, with increasing feelings of self-efficacy and respect, the individual may move forward with their development of social identity which in turn permits capacity building and further skill development.  The exact issues which need to be addressed through education, specifically what skill development would best enable the beer girls to move forward,  was ascertained through the use of multi- method triangulation (Koelen, Vaandrager & Colomer, 2001).
	Following the risk factors identified through the focus group, interview and clinical behavioural data, a pyramidal peer education programme was designed and implemented in Siem Reap during May of 2002.  This program followed the Health Belief Model in stressing “the importance of promoting positive beliefs about disease prevention and condom use as well as developing self efficacy for condom use and condom negotiation” (Ford et al, 2000).  A short questionnaire was dispensed immediately following the conclusion of the training session and in-depth follow-up interviews were conducted with 7 of the peer educators in July of 2002 (Appendices 6, 7, and 8).

Cultural Sensitivity Translation Problems
	Due to the cultural difference between the academic researchers and the population of interest, a series of cultural sensitivity issues arose through process of designing and running the peer education training process. A primary concern throughout  the interview process was the use of a translator to relay questions and answers between the interviewer and interviewee.  Because these translations were not done “word-by-word” but rather for meaning, it is possible that issues were not understood by the researchers as the interviewees had portrayed them. Because of the cultural mores around women’s sexuality and sexual activity, researchers had to work very carefully in order to not offend or embarrass the women being interviewed.  This also meant that some of the questions of interest to the researcher could not be asked directly about their own behaviour, but rather broached carefully and based on typical beer girl behaviour. Occasionally male researchers and translators were asked to leave a session so that gender-sensitive issues could be addressed more comfortably.
	In a population which for the most part cannot read, stumbling blocks were therefore encountered in designing questionnaires and/or  communicating basic health  statistics and percentages in a meaningful way.  Cultural sensitivity was required in dealing with the educational level of the women in the group, as the Likert-scale rating system was completely unfamiliar and confusing for the women.  Some traditional methodologies simply did not work with the women of Siem Reap, and it was up to the researchers to assess response to the materials and to change them instantly 17.

	In compliance with the protocols of the University of Guelph for treatment of subjects in a research project, all efforts were made to ensure that ethical guidelines were followed.  Individuals were advised that the conversation was being recorded and that they could remove themselves from the interview at any time.  They were also informed that their name would be removed from the transcript to ensure their anonymity, and that only aggregate statistics would be used in the data analysis which followed the interview.  When photographs or videos were taken with their permission, it was arranged to not show their faces or to pixelate photographs to preserve their anonymity.

Results
Contextually Situating the Siem Reap Beer Girls: The Pre Intervention Phase
	The combined 54 tape segments yielded specific information given by each woman in regards to their personal background, employer information, condom use, health knowledge and training, and social support.  Because it was not always feasible to be completely systematic in interviewing in AR field settings, for example, the number of responses varies considerably;  percentages of respondents will only refer to those in the sample who are asked the specific question, not the total sample of 54. 
	The average age of the 37 AR women in the sample who responded was 24.5 years, with ages ranging from 18 to 32 years [compared to a mean of 24 years in MM, with a range of 16-31]18.  A significant positive relationship was established using a Pearson Product-Moment correlation between positive HIV status and date of birth, r(31) = 4.96, p < .01.  The majority of women in both the AR and MM groups were single, with the next most common marital status being divorced (Table 1).  Eleven (31%) of the AR women of the 35 who responded to the question of maternity were mothers [compared to 14 (52%) of the MM women], and 25 (out of 33 AR women, 75.8%) were responsible for financially supporting family members (including children, parents, siblings) [in the MM sample, 34 (97%)].  Relationships were found to exist between how many people the ISW supports and positive HIV status, r(31) = .426, p < .05, and between how many men slept with during a usual week and the number of people the ISW is supporting, r(31) = -.354, p < .05.
	There was great range in the levels of education reported by both the AR and MM samples, with 65% not having reached secondary school of the AR group, compared to 59% for the MM group (Table 2).  Two of the AR women reported attending the Rose Centre, learning English and to read and write in Khmer.  The reported literacy of 34 of the AR women was 47% (16 women), with three of 39 (7.7%) reporting the ability to speak English.

	Previous employment status in the AR group (of 29 responding) showed a wide variety.19  Five women of the AR sample reported supplementing their beer girl income with other jobs, including: selling porridge and mixed drinks, working in the rice fields by day, construction worker, food preparation at the market, and selling porridge out of home.  Future ambitions given by those who were asked about their aspirations were: further education, becoming a small vendor, hairdresser, owning a boat, selling (groceries, cloth, table wear, cosmetics, miscellaneous goods, rice), becoming a hairdresser or beautician, learning English, becoming a tailor, cooking in a restaurant, operating a beautystore, and becoming a doctor, nurse or lawyer [in the MM data, 4 (11%) wanted to learn to use computers, and 31 (89%) wanted to learn “other”].  The diversity in expectations and hopes for the future can be observed in the AR sample, as several of the woman indicated more than one future aspiration, one woman wanted only to return to her village, another wanted to raise her children, while another did not offer any ideas due to self-proclaimed uncertainty for the future.
	The companies represented by the AR sample included: ABC (Stout), Tiger Beer, Fosters, Alain Delon, Angkor, Anchor, Heineken, Stella Artois, Beck, Singha, Carlsburg, San Miguel, Labatt’s Ice, Spy (wine cooler), wine and cigarette sellers, and a woman who did not state the name of her employer [comparative MM data included women employed by Angkor, ABC (Stout), Tiger Beer, Heineken, and Fosters].  Five of the AR women had previously worked for another company, including the 2 women selling Spy who had switched from selling beer to wine coolers.   The average total length of time of working as a beer girl of the 38 AR women who responded was 1.5 years, with a range of one day to 6 years [comparative MM data showed a mean length of ISW employment of 1.2 years, with a range of 4 months to 2 years].
	The AR women employed by Tiger, ABC, Heineken and Anchor reported receiving condom compliance training; one suggested that there was also HIV testing provided once a year.  This means that out of the 53 AR women, only 25 (47%) had attended an educational session organized by their company.  San Miguel and Fosters had both run similar sessions for the AR women in the past, but the current training received by the beer girls employed by these companies is uncertain.  This training, which occurred in the respective company’s warehouses, lectured the women with information about how to use Number One, protecting themselves from disease and other “advice”.  The women who had received this training deemed it to be “helpful”.
	A discrepancy exists between the number of women reporting having been tested for HIV and the number attending the yearly session through their beer company.  The number of AR women who reported having been tested for HIV was 8, so that it seems unlikely that HIV testing was systematically occurring with training sessions (n= 25 attending).  Two of the AR sample reported going on their own to have testing done “often”, but no frequency for this behaviour was obtained [in the comparative MM data, all 35 (100%) had been tested for HIV].  Of the AR sample, 12 women had known or had seen someone dying from AIDS, or symptoms which they believed to be related to AIDS [MM data showed 10 (28.6%) of the sample knowing someone infected with HIV or who had died from AIDS].  One of the AR women was concerned that she had tuberculosis, while another was scared that she was HIV+ because her husband had died the year before.
	Due to the variability of question asking and hence responses from within the AR sample of 54, summary statistics cannot be provided for all items; but specific issues of interest and general impressions noted during the analysis will be further explored in the discussion section.  The MM data, however, does provide some systematic behavioural data about the ISWs interviewed.  Due to the many similarities between the AR sample and the MM sample in terms of demographics, the behavioural results may not be unlike those which might be expected from the AR sample.

Clinical Behavioural Data
	Of the 35 women in the MM sample, 5 (14%) tested positive for HIV.  The mean earnings per month in US dollars was 83.5, with a range of 50-100.  During a usual week, the average number of men with whom the 34 reporting MM women had had sex was 4, with a range of 1 to 15 (one woman did not respond).  Of these men, 20 (60.6%) were clients, 7 (21.2%) were boyfriends or fiancees, 6 (18.2%) were their husbands (two women did not respond).  The number of men slept with during a usual week was found to be significantly correlated with earnings per month, r(31) = .502, p  < .01.  In terms of relationships related to risk positioning, a significant negative relationship was obtained between how many people slept with during the last week and how many people the ISW were supported, r(34) = -.377, p< .05.  Earnings per month correlated positively with how many men slept with during the last week, r(34) = .487, p < .01.
	Of the 13 MM women who reported having slept with more than one man during a usual week, these men were 8 (61.5%) clients, 3 (23.1%) boyfriends or fiancees, and 2 (15.4%) husbands.  Perception of partner’s chance of having AIDS was found to be significantly negatively correlated with the number of men slept with in a usual week, r(23) = -.450, p < .05.  Condom use with paying partners in the usual week was most frequently indicated to be everytime by 67%, while condom use with non-paying partners was most frequently indicated to be never and that by 58.8%, and only 5.9% reported using condoms everytime (Table 3).  When asked if they had asked any of the men to use a condom, of the 30 women responding, 16 (53.3%) reported asking all the men, 7 (23.3%) asking some, and 7 (23.3%) reported having not asked.  Of the men asked, the MM women who responded on average said that 54% had agreed to use condoms.
	When men refuse condoms, of the 28 women responding, 16 (57.1%) reported always refusing vaginal sex, 5 (17.9%) sometimes refusing vaginal sex, and 7 (25%) reported not refusing sex.  A significant negative relationship was established between refusing sex for men who would not use condoms and positive HIV status, r(25) = -.469, p < .05.  Refusing to have sex with men refusing condoms was positively correlated with her own perception of being HIV positive, r(24) = .624, p < .01, and knowing someone with HIV, r(25) = .479, p < .05.  When men refused to use condoms, of the 28 women responding, 12 (44.4%) reported offering alternatives to ‘keep the client’, while 15 (55.6%) reported not offering alternatives.
	In terms of behavioural reporting, questions pertaining to condom use in the last week were used.  Of the 35 MM women, 9 (25.7%) reported having a boyfriend, 8 (22.9%) reported having a husband, 16 (45.7%) did not report being in a relationship, and 2 (5.7%) did not respond.  Of the 9 with boyfriends, 8 (88.9%) reported having asked them to use condoms, 1 (11.1%) reported not asking, and only 3 out of the 8 (37.5%) had their boyfriend agree to use a condom.  Of the 9 with husbands, 2 (22.2%) reported having asked them to use condoms, 7 (77.8%) reported not asking, and only 1 agreed to use condoms.
	Of the MM sample, 31 responded that in their last sexual encounter, 24 (77.4%) had slept with a paying partner and 7 (22.6%) with a non-paying partner.  During these encounters, 25 (80.6%) reporting having used a condom, 4 (12.9%) reported not having used a condom, and 2 (6.5%) could not remember if a condom had been used.  In responding to who had suggested condom use at that time, of 29 MM women, 16 (55.2%) said “myself”, 4 (13.8%) said “my partner”, 6 (20.7%) said “joint decision”, and 3 (10.3%) gave no response.  Pearson product-moment correlations revealed a relationship between how many of the men (last week) used a condom and earnings, r(29) = .433, p < .05.  In addition, the longer she worked in the entertainment industry the more likely she was to have her partner agree to use a condom when asked,asked, r(3) = .973, p < .01.  As well, knowledge of the ability to protect herself using condoms was positively related to how long she had worked in the entertainment industry, r(31) = .379, p < .05.  Of 17 answers for why a condom was not used the most frequent response was “I trust him” (41.1%), while 23.5% had said that their “partner objected”, 11.8% “didn’t know how to persuade”, 11.8% blamed “too much alcohol”, 5.9% said “I love him” and 5.9% “I didn’t think of it”.
	All 35 women had heard of diseases that can be transmitted through sex, and 34 (97%) had heard about HIV or AIDS.  The perception of risk for having HIV/AIDS showed that only 14.7% of the women felt they had no chance of having AIDS, while 26.9% felt that their most recent partner had no chance of having HIV/AIDS.  Similarly, they attributed only 26.9% of their partners to have a high or quite high likely of HIV, while for themselves it was 47% (Table 4).  Knowledge about HIV/AIDS was diverse among the MM sample, with 85.7% of the women saying that they did not know if they could protect themselves from HIV by using a condom correctly everytime they had sex and 48.6% saying that they did not know if a person who appeared healthy could be infected with HIV (Table 5).  When asked where they had heard about the need to use condoms to protect themselves from AIDS and what their major source of information about AIDS was, the majority indicated television (Table 6).  Beer girls were proportionally more likely (4/11) to have heard about AIDS prevention from Siem Reap NGO than the other types of ISW (2/23), χ2(1) = 3.925, p < .05.

Post Intervention Interviews
	A total of 7 women participated in a series of post-intervention interviews in July 2002.  Six of the women (85.7%) reported having made new friends since the workshop through their teaching.  The average number of people taught was 4, with a range of 1 to 10.  When asked if the information was useful in their own life, 5 (71.4%) reported using the information with men.  All 7 of the women now reported safe sex practices, stating 100% condom compliance with all men.  Two of the women (28.6%) reported that it was easier to teach older people, and 3 (42.9%) reported having an easier time teaching men than women.  A concern noted by two of the women was that they were unable to answer some specific questions about health and STDs asked by their students (they were referred to the peer education supervisor).  One woman noted that her teachings were not always respected by others because the others are of the same “capacity/ability”.  Although not specifically asked whether they knew someone who had died from AIDS (unlike in previous focus groups), 4 spontaneously brought up the subject of a beer girl recently dying.
				
Discussion

“Never doubt that a small group of concerned citizens can change the world; indeed, it’s the only thing that ever does.” - Margaret Mead, as quoted by Bettencourt, 1996, p. 207

	The goals for the beer girls in the peer education project included: 1.) enabling the women to change their personal behaviour, and 2.) giving them the skills and knowledge with which to pass this information on through teaching other people.  In studying the pre and post-intervention data it becomes clear that success was found with both goals, more quickly with personal behaviour, but slowly through initial forages into teaching others.  Much of the information obtained during the focus groups and interviews in 2001 and 2002 – as well as the 7 follow-up post intervention interviews– was ideographic, this data will be reviewed as it provides a series of “snapshots” of the context of the concerns, knowledge and needs of the beer girls of Siem Reap, and because such anecdotal evidence provides an indication of the changes resulting since the intervention.  When used in combination with previous findings and literature, a more comprehensive picture becomes visible regarding the lives of the beer girls in Siem Reap.
	Pheterson (1996) states that women may migrate to fulfill familial obligations, as daughters may earn less than sons but are likely to send a larger portion of their income home out of a sense of familial obligation.  The decision to migrate from a rural area to an urban one is often made on the basis of need for money, escape from abuse, or in search of autonomy (Pheterson, 1989).  This filial obligation was noted during analysis of the interview data, as a large percentage of the women were supporting family.  Further, the relatively high level of divorce in the group is illustrative of Pheterson’s (1989) point that many women leave their village because they had to find some way to survive after divorce, or because their husbands did not provide for them.  According to a number of women in the focus groups, common experiences of women who become beer girls in Cambodia included poverty and divorce.  Closing of factories and abusive home environments were other factors, which, in combination with a lack of training for other types of work, create a perilous situation where money takes precedence over personal safety and happiness.
	The difficulty in targeting beer girls for intervention can be noted in the isolation between beer girls due to the diverse geographic location of their homes, as became apparent in analysis.  This geographic spread was evidenced in the interviews by a number of beer girls who replied that they were bussed in to work at the restaurants from the countryside.  The geographic spread can be used to explain the isolation and low group cohesion noted by the beer girls.  The lack of social ties may also be due to emotional detachment, as Pheterson (1996) postulates that the need for detachment on the job can have pervasive effects on the emotional life of the women involved in prostitution.   This detachment became obvious when queries into social relations between beer girls were frequently met with statements about the women having nothing but poverty in common.  The only discussions shared between the beer girls involved dislike of their work.  However, this is an important starting ground, as this commonality can be used as a basis for building a social support network among the beer girls.   Finally, this detachment may also be due to the desire to distance oneself from the stigma connected to their individual and group identity due to occupational circumstance.
	The lack of social support was glaringly obvious during interviews with two of the beer girls.  One of the women, when asked about social support from her friends and family, said that she doesn’t expect other people to help her when she’s upset, rather she listens to a song she selected on her cassette player.  She said that she keeps her sorrows secret, not speaking to her family, but trying to release them by listening to the song.  Another beer girl spoke of being raped and beaten by a man after work one night and being unable to tell anyone.  This internalization of upset may be due to cultural constraints, for example about premarital sex and keeping family reputation.  Such feelings are difficult to target through intervention.  Perhaps confidential counselling would provide these women with an outlet through which to vent their sorrows while still keeping their family’s honour intact.  Currently, such counselling is not readily accessible within Siem Reap.
	Not all perceptions of the job were negative, though, as one beer girl responded that a positive aspect of the job was that she only had to work during the evening, and because of this was able to also work as a part time rice farmer.  It is interesting to note that the one woman who had been a beer girl in Australian had displayed a sense of empowerment in stating that with working harder, it became possible to make more money.  When viewing the work as a business exchange, similarly to the women in Roni and Ellis’ (1989) study, it becomes possible to maintain a sense of control over the exchanges with customers.  This theme was again noted when one woman said that she wanted to be paid per case as she was not being paid for her hard work, while another said that she wanted to be on salary because she was not making enough money.  This again suggests the importance of empowerment in motivation, as the women who are empowered see themselves as business women and are able to move more product thus making more money and maintaining a sense of control.
	Queries about stigma received a variety of responses, all of which indicated a high perception of job-related stigma.  Because of this intense stigma, several women were afraid of being unable to find another job.  One woman spoke of instances where patrons tried to pull her into cars, and another spoke of the dislike the married women of Siem Reap held for women in their occupation.  In terms of customer relations, one beer girl said that feeling safe depends on the customer.
	The mean earnings reported per month was of $83.5 US dollars, with a range of $50-$100.  This is of interest, as the majority of women make less than $60 per month from the beer companies, so the excess income is most likely coming from selling sex.  It was expected that a positive relationship would be found between the number of people slept with and economic obligation (i.e. family to support).  Instead, a negative relationship was obtained between these factors.  Interestingly, a significant relationship was found between the number of people the ISW is supporting and positive HIV status.  This contrasting data about economic obligation may somehow be linked to how much the women are paid per episode of selling sex, or possibly an artefact of our difficulty in factoring out their base salary from sex work income.  It is possible that work may be skipped in favour of having a client (an income difference of $2 vs. $20).  Another alternative might be that the beer girls are each making a mean of $60 per month and supplementing their income with only a few clients (one or two a month at expected beer girl rates of $20 per night) then  they may be able to judge exactly how many customers extra are required each month to take care of their families, and only accept a few of the $20 offers.  Another explanation is that because of the number of people for whom they are responsible for care, there may be less of an opportunity to stay overnight with paying customers.  Because different types of ISW were included in the MM sample, it is possible that some of the massage girls whose work is closer to being that of a brothel worker accepted more clients rather than having total choice as the beer girls do.  These women may not be able to refuse customers and may not have a base salary, making their income dependent on having more clients.   A significant positive relationship was also established between earnings per month and how many of the men last week had used a condom.  These findings were supported by Wong et al (2001), who found that higher income level was one of two factors related to the ability to enforce condom compliance.
	Overall basic knowledge of the existence of STDs and AIDS was high, with all of the women having heard of diseases that can be transmitted through sex, and all but one having heard about HIV or AIDS.   Alarmingly, when asked if they could protect themselves from HIV by using a condom correctly everytime they had sex, 85.7% said they did not know.  This is in contrast to the results of the direct sex workers (DSWs) shown by Wong et al (in press), who found that 90.7% of the DSW knew about the effectiveness of the condom in prevention of HIV infection.  When the women knew someone with HIV/AIDS they were more likely to refuse sex with any partner resisting condom use.  This may indicate that first-hand knowledge of HIV/AIDS contributes to perception of own vulnerability to infection.  A corollary of this was the negative relationship found between the perception of the partner’s chance of having AIDS and the number of men she slept with during a usual week.  In addition, the positive correlation between perceiving herself to have a high chance of having AIDS and refusing sex with men who won’t use a condom indicates that, in fact, these women are willing to change their sexual behaviour when risk is perceived to be great.
	The positive relationship found between HIV status and date of birth is supported as well by government statistics on the rate of seropositivity among older direct sex workers (DSW) found by the Cambodian Ministry of Health in Siem Reap (National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, 2001).  According to the same source, among ISW the rates are highest in the 20-29 age group in Siem Reap, with 21.6% testing seropositive in 2000 (National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, 2001).  This age group is where the majority of the women in both the AR and MM samples were found, and thus the higher prevalency among women of this age group is of concern.  In Siem Reap, the HIV prevalence rates for  ISWs and DSWs are much closer than those in the general population or in other provinces, with rates of 28.7% and 20%, respectively (National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, 2001).  While the government’s peer education program is already in place for the DSWs, this highlights the necessity to target more interventions specifically for the ISWs as sex workers.
	Condom use with paying partners in the usual week was much higher than condom use with non-paying partners in the usual week, with everytime (100% condom use) being reported with paying men (clients) 66.7% of the time, but only 5.9% with non-paying men (boyfriends and husbands).  Condom use was much more likely to be initiated by the women than by their partners.  A difference between paying and non-paying partners was also obtained by Wong et al (2001), who found that consistent condom use to be much higher with paying partners than with non-paying partners and likewise found that women were more frequently the initiators of condom use.  The rates of condom use were much higher in the Wong et al (2001) study for both types of partners, 77.9% with paying partners and 20% with non-paying partners.  The dramatic different in condom use between clients and non-paying partners is seen by health officials as an important reason for the spread of the epidemic in places such as Siem Reap where the local men, with their inconsistent condom use are seen as “bridges” for the epidemic.  This knowledge is crucial to stress in all training sessions for our peer educators within the community.  When we discussed the issue of condom use with non-paying partners, one woman suggested that it became hard after a couple of years to get the men to wear a condom, as the man would get “worried” about her state of health when he was asked.  Another beer girl said that she does not need condoms because she only makes love with her boyfriend, and they do not use a condom because they did not from the beginning of their relationship and it would be hard to start now out of habit.  Another beer girl said that her boyfriend only used condoms immediately prior to ejaculation.  This is one example of where love and trust within a relationship can be considered to be constraining factors, placing the women in a position of risk (Willig, 1997).  Recall that in 41.1% of the cases the reason women gave for not obtaining condom compliance was because “I trust him”.
	Another of the reasons given by women in the MM study as to why condoms were not used was the involvement of alcohol in the exchange.  While the beer girl who had worked in Australia had a number of trade secrets (ways to avoid intoxication while still appearing to drink with the customer), no similar ideas emerged in discussion the beer girls of Siem Reap.  This is an issue of concern, and needs to be incorporated into skills training along with condom persuasion skills.
	Since condom persuasion was given by some women throughout our samplings as a skill they were lacking, condom persuasion tactics were addressed in the training session, telling women to appeal to issues affecting the quality of the men’s families, their work, and their reputation.  One beer girl said in a post-interview session that she now tells men that they are very young so they need to protect themselves so they can live a long life, and that this is a successful persuasion tactic.  This points to a success of the intervention project, as this woman was able to directly apply one of the ideas from the workshop and it’s training materials into her own life and thus used them to protect herself.
	Refusal of sex when men will not use condoms is an issue of concern.  Because of the economic pressure on the women to earn money to support their family, it is perhaps not feasible to expect them to refuse sex everytime.  The MM women reported that on average 54% of the men (clients and boyfriends) with whom they had sex had agreed to use condoms.  While some women indicated offering alternatives when the partner will not agree to condom use, this was not a skill utilized by all of the women (43% reported not offering alternatives).  The comic books used in training the peer educators and in their subsequent teaching sessions address the use of alternatives to vaginal sex, and this idea was received enthusiastically and evaluated highly during the training sessions when the women were encouraged to discuss ideas in small groups and role play.  Because of the success found by utilizing the role playing and group discussion approaches, these methods should be applied in further training.  When asked why she should use condoms, one beer girl said “Life is important- want to see the future, see the rest of the world...”, indicating knowledge of how to protect herself, the attitude of wanting to do so, and suggesting the importance of skills with which to enforce this behaviour.
	As one beer girl said, “sometimes men have a lot of money and some of the girls don’t have any concept”, demonstrating a need for training on how to negotiate condom use.  However, training is typically not given by companies, as they tend to provide training on pouring and drinking their product, rather than about employee health and safety.    It was surprising that TV and radio were ranked highest as the medium for information for women about the need to use condoms and their main source of information about AIDS.  During the focus groups, videotapes had not caught the attention of the beer girls and so audiotapes were created instead.  More thought needs to be given to the role of television in Siem Reap.  It was, however, not surprising that none of the women had heard about condoms from their clients. 
	While perceptions of intervention involvement were overall quite positive, one woman suggested that they last too long.  The concern here was echoed by several women invited to attend the peer education training session, as missing work means missing income or time with their families.  This necessitates the use of incentives for involvement in training and continued involvement (such as in the peer education program).  These incentives can be problematic, as demonstrated by one woman in the post-interviews saying that she was quite jealous because she had heard that one of the other teachers had been given a cassette player to use with her teaching while she had to visit one of the supervisors to borrow one each time she was teaching.  It is difficult to maintain a reward system which keeps the peer educators motivated to perform their task, and which does not alienate them from each other.
	However, continued involvement is encouraged by the increasing number of programs targeting these women at risk, such as the government program which was referred to several times during the post-interviews, credited with offering increased knowledge and additional materials.  In fact, when the beer girls were compared to other ISWs in the MM sample, they were significantly more likely to have received information from the Siem Reap NGO (which ran the workshops).
	The average length of time as an entertainment worker was just over one year, and length of time in the industry was positively correlated with how many times the most recent partner had agreed to use condoms and her own knowledge of the ability to protect self using condoms.  This would suggest that during the time of employment, knowledge increases about persuasion and STD prevention.  This may be due to exposure to intervention programs, information in the media, or many other sources.  The increased knowledge level of the “senior” beer girls can be capitalized upon through their placement as teachers in the peer education training program.  This ability was observed one evening in a beer restaurant when a “senior” beer girl spoke to a new beer girl about dealing with customers and protecting herself.  One of the beer girls who was recruited as a peer educator said that she makes a point of pulling aside new women and explaining to them the danger of HIV and how to protect themselves.  Two of the women interviewed post-intervention had been new to the job of beer girl when recruited for involvement with the peer education project.  Both women stated that they are becoming increasingly comfortable with the job, and it is clear that this comfortability is related to their increasing knowledge about how to keep themselves safe at work and at home.
	The effectiveness of the peer education training program was profound throughout the post-intervention interviews.  When asked if the information was useful in their own lives, one woman said that she “knows how to protect self, manage her partner, convince or persuade the man who would like to go with her”.  True impact of the project can be noted in the total sample answering that they were 100% condom compliant with all men since the workshop.  One of the women said that she changed a lot as a result of the workshop, and found another job in order to change her life.  Seemingly, involvement in the program gave her the self-confidence she needed to become active in changing her own situation.  This confidence was seen in another participant as she said spontaneously during an interview that “trusts herself that she can teach, afraid for future when children grow up.  She might try to change herself to work to make more money to take care of her children.”  These changes in the womens’ personal lives provide powerful evidence of the attainment of the first empowerment goal of the peer education project– changes in own behaviour.
	Evidence of the second empowering goal to be able to teach others was found in the post-interviews with the women having taught an average of 4 other people.  Interestingly, their “students” were not only other beer girls, but included men, neighbours, and friends who were not beer girls.  Further evidence of this spread of teachings from this small group of women out into the larger community also emerged during the interviews.  One of the women, working mornings as a construction worker, said that she tries to explain to her male coworkers during breaks to protect themselves with condoms.  This woman wears her peer educator t-shirt to the job site.  Another of the women interviewed was actually wearing her t-shirt during the interview at the beer restaurant where she works.  These shirts were said to act as a conversation opener.  Both women stated that people are curious when they see their t-shirts, asking “are you a teacher of AIDS?”
	While data is presently unavailable for the rating of the sessions, this group indicated not having difficulty with the materials.  Several of the women listed their favourites, which included the cassette, flip chart and comic book.  Journal use of the 4 women who responded was overall viewed positively, with 3 of them using the journal to record students and problems encountered in their teaching.  Several of the women indicated a problem in that their own personal knowledge level was of hindrance in their teaching with others.  These women indicated that when they were unsure of an answer to their students’ queries they were unsure of what to do next.  One of the women had recorded the questions in her teaching diary.  This would suggest that further information about HIV/AIDS beyond the basics would aid these women in their teaching, and the support of the supervisory staff here is crucial.
	Of great concern to several of the women involved in the post intervention interviews was the recent death of a beer girl from AIDS.  Because the woman had no family to secure a funeral for her, her body had been unceremoniously cremated by the police.  One of the women indicated that this was a fear of hers, but said that if she tried 100% condom compliance she might be safe.
	A positive aspect of this pilot project is that a wide range of international beer companies were represented within both the AR and the MM data.  It was noted that the age range of the women in this sample was older than that which is stereotypical of beer girls (i.e., the manner in which they are portrayed in the media).  Perhaps this difference was due to a selection bias,  as Lubek and Wong (2001) were looking for women with potential as peer educators and for representatives from the various international beer companies operating within Siem Reap.  However, through the AR data collection cycles, difficulty was found in obtaining systematic data due to the perpetually changing nature of the AR environment, and behavioural data was difficult to obtain as asking questions about sexual behaviour and activities were not always appropriate, for example in focus group settings.  Of methodological concern is social desirability bias, particularly when dealing with such a sensitive and culturally constrained topic as sexual behaviour and practices in women.
	Other positive aspects of the pilot project included the use of grassroots methodology in assessing the economic, cultural, and relationship factors which enable and constrain women to act in Siem Reap, the retooling of materials which had found success in other cultures to meet with Khmer culture, and skills training which addressed the  knowledge-practice gap which so often plagues health education training. The success of this pilot project will continue to be evaluated in additional follow-up interviews during the year to come.
	According to the Ministry of Health in Cambodia (2000), 10% of rural men and 12.5% of urban men report having had sex with their wives as well as with commercial sex workers and/or “sweethearts”.  Thus, the local men in Cambodia are hypothesized to act as a “bridge” between the sex workers and their wives and/or sweethearts.  Men are defined as “bridges” if they reported having sex with both high risk (commercial sex workers) and low risk (wives and/or sweethearts) partners in the past year (Sopheab et al, 2000).  According to the Cambodian Male Household Survey (Sopheab et al, 2000), high risk for transmission is perpetuated by these so-called “bridgers”to the general population from core groups.  Thus, the inclusion of men into the next data-gathering cycle of this dynamic and reflexive AR project will be a valuable addition to the ever-widening knowledge base from which intervention materials are designed and evaluated.
	A major barrier to HIV prevention and care among infected people and at-risk groups is stigmatization (Ministry of Health, 2000).  The stigmatization faced by the beer girls of Siem Reap due to their risk positioning may be to blame for the steady rates of seropositivity among beer girls.  The 2000 sentinel report issued by Ministry of Health states that the HIV prevalence was lower in 1998 and 1999 in all sentinel groups except for beer promotion girls. This is of great concern, as the positioning of beer girls as being neither DSW or married women creates a special situation requiring a specifically designed intervention.
	The value of information obtained through focus groups and on-site interviews with beer girls and other qualitative methods of obtaining information about their backgrounds, their peer support groups and hopes for the future lies in determining why these ISW first begin sex work and what happens to them once they have stopped selling sex.  According to the Ministry of Health (2000), it is possible that women leaving the sex trade and starting families unknowingly pass the infection on to their spouses and children.  This information also aids in contextualizing the context of the choices made by these women as well as looking at changes in sex work, including definitions of sweethearts and regular clients (Ministry of Health, 2000).
	This thesis has demonstrated health, education and social needs within the beer girl population, all of which are acutely related to socially based stigma.  The literature reviewed regarding the Khmer culture, and the status of women within the culture, has shown that the stigma effects related to their occupation are pervasive and life altering.  Stigma and prostitution theory have shown that the societal affects of both the individual and collective identity of the beer girls accumulate to maintain the status-quo faced by these women and prevent them from gaining empowerment- both as individuals and as a community.  Lessons learned through the forages of other researchers into similar grassroots AR projects have demonstrated a great need to focus on short-term successes and to continually seek feedback from the target group regarding their perceptions about the impact that the program is having on their lives.   
	Overall, the research questions with which I entered this project have been addressed.  Analysis of data gathered from beer girl interviews over the past three years has provided a context for who these women are, the risk behaviours they engage in, as well as help establish what was their pre-intervention knowledge level about HIV/AIDS was.  A workshop was subsequently designed and carried out, which appears through preliminary analysis to have been successful.  I participated personally in these workshops and came away with a “subjective” impression that this was the case.
	The question of the attainment of empowerment within the beer girl community of Siem Reap is one which will require further observation and perhaps further encouragement.  In light of the complexities of the context in which the risky behaviours of the beer girls occur, further research will need to measure effects of the intervention over a long time frame, and would benefit from using both qualitative and quantitative methodologies, including some form of formal program evaluation.
	This project is constantly reshaping itself and seemingly never-ending because of the participatory action research notion that once evidence of found of the success of an intervention aspect, it is immediately incorporated into the methods and procedures.  During sessions, the needs and concerns of the group may take precedence.  Several times, in focus groups and in workshops, scheduled activities were stopped in order to respond to spontaneous actions or questions from the beer girls.
	According to Bettencourt (1996, Appendix 9), while grassroots groups may organize initially to find a collective solution to one problem, the skills which they acquire in the process may subsequently be used to work toward achievement of other goals.  This process is analogous to the metaphor of a drop of water causing ripples, as the effects of the one drop spreads and has an effect on the whole body of water.  In this way, initially addressing the education, health and safety needs of the beer girls as a collective group creates a potential for fostering a collective identity through empowerment at an individual, community, as well as societal level.  The resultant changes stemming from this multi-level empowerment transition have the potential to lead toward affecting the status of women within their culture, labour practices and the promotion their sexual autonomy and self-actualization.
	MAP (2001), suggests that because the majority of the Asian population does not engage in high-risk behaviour, interventions focussed on those who engage in risk-behaviours is effective and affordable.  These programs are suggested to be most effective when implemented during the early stages of the epidemic when the epidemic is affecting risk-groups, before the infection spreads into the general population.  Therefore, interventions put in place for the indirect sex workers may prove to be integral to preventing the further “bridging” of the epidemic into the broader Cambodian population.

“In that situation girls got a chance to work with garment factory but more girls remain without jobs so girls had to find a job as beer or wine sellers for tiger beer or another companies.  It was easy to make girls become prostitutes, they worked at night.  Since this is a traditional culture, society does not consider them as a good people, and this situation made girls feel hopeless in their lives.  Gradually, girls became rejected by society and spiralled downwards.  This is why HIV/AIDS has increased 180% affecting not only these women but also wives and children who are not involve in prostitution.
Situation of girls in Cambodia is very dangerous.” 	- Chea Muoy Kry, 1999

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Appendix 1
Prostitution questionnaire for all-women (adapted from Pheterson, 1996, appendix A)

Circle as many responses as apply

1.  What positive forces contributed to your going into prostitution?
	a.  none
	b.  desire for independence
	c.  desire for adventure
	d.  enjoyment of sex
	e.  expectation of money
	f.  curiosity
	g.  professional ambition
	h.  togetherness with friends
	i.  desire for power
	j.  a sense of responsibility
	k.  other forces: ______________________________________

2.  What negative forces contributed to your going into prostitution?
	a.  none
	b.  not enough money to support myself
	c.  not enough money to support children
	d.  not enough money to support parents, family
	e.  not enough money to finance an education
	f.  lack of alternatives
	g.  fear of losing love, please specify:________________________
	h.  pressure from others, please explain: _____________________
	i.  being labelled a whore
	j.  powerlessness
	k. other: ______________________________________________

3.  How do you view prostitution?
	a.  as a business
	b.  as an art
	c.  as exploitation of the prostitute
	d.  as giving therapy
	e.  as a career
	f.  as a trade or skill
	g.  as a lifestyle
	h.  as a relationship
	i.  as intimacy
	j.  as coercion
	k.  as supplementary income
	l.  as a hustle
	m.  other: _____________________________________________

4.  Age at first intercourse
	a.  less than 10 yrs old
	b.  11-15 yrs old
	c.  16-20 yrs old
	d.  older than 20 yrs

5.  Which statements best describe the friendships in your life?
	a.  my best friends are (circle one):
		women		men		both women and men  
	b.  I tend to have one close friend
	c.  I am a part of a sub-culture of people with similar social status to my
	     own
	d.  my mother and I are close
	e.  my father and I are close
	f.  I never trust anyone completely
	g.  I am basically a loner
	h.  other attitudes toward friendship: _________________________

6.  Which statements apply to the intimacy in your life?
	a.  I have (had) a primary relationship in my life.
		how long have you been (were you) together?________________
	b.  I do not have a primary relationship and I prefer it that way.
	c.  I do not have a primary relationship and I would like to have one.
	d.  I have lover(s) who I distinguish from my primary relationship.
	e.  I have lover(s) and no primary relationship.
	f.  intimate relationships are problematic for me.
	g.  other attitudes toward intimacy: _____________________________

7.  Marital relationships:
	a.  status (circle one)
		single		married	divorced	widowed
	b.  I am or was happy about being married (circle one)
		always	often		sometimes		rarely		never
	c.  I hope to be married (again) in the future
	d.  marriage is not for me
	e.  other feelings about marriage: _____________________________

8.  From whom have you experienced stigmatization or exclusion?
	a.  no one
	b.  mother
	c.  father
	d.  siblings
	e.  children
	f.  friends
	g.  neighbours
	h.  landlords
	i.  (prospective) employers
	j.  co-workers
	k.  a lover
	l.  other: ______________________________________________

9.  Work experience
	a.  describe setting and nature of current work:_____________________
	b.  setting and nature of past work: ______________________________
	c.  approximate income:
		hourly:_________________
		weekly:_________________
		monthly: ________________
		yearly: _________________
	d.  of all jobs you’ve had, which have paid the best? __________
	     _________________________________________________

10.  How satisfied are you with your current job?
	a.  I like it, and can imagine doing it my whole life
	b.  I like it for now, but I hope to move to something else
	c.  it’s okay.  I don’t think about the future
	d.  it’s okay.  I fantasize about doing something better
	e.  I don’t like it, and only plan to do it temporarily
	f.  I don’t like it, but I don’t see any alternatives now or in the future
	g.  other comments about job satisfaction: _____________________

11.  How did you get into prostitution?
	a.  I was encouraged by another prostitute
	b.  I was encouraged by a manager
	c.  I saw friends working and took the initiative to join
	d.  I started working without knowing other prostitutes or a manager
	e.  I was coerced
	f.  other: ________________________________________________

12.  Did anyone train you? ______________________________________

      How would you evaluate the training?
	a.  extremely helpful
	b.  sometimes helpful
	c.  irrelevant
	d.  sometimes hurtful
	e.  extremely hurtful
     If you didn’t receive any training, do you wish you had? ________________

13.  How long have you worked as a prostitute?________________________

14.  At what age did you start work as a prostitute? _____________________

15.  What health problems do you have (or have you had in the past)?
	a.  none
	b.  fatigue/exhaustion
	c.  frequent colds
	d.  venereal disease
		gonorrhea
		syphilis
		herpes
	e.  vaginal infections
	f.  back aches
	g.  sleeplessness
	h.  headaches
	i.  depression
	j.  stomach aches
	k.  eating disorders
	l.  HIV/AIDS
	m.  other: _______________________________________________

16.  What aspects of your job do you think contribute to any of the above
       problems?
	a.  long working hours
	b.  pressure to perform
	c.  dislike of work tasks
	d.  harassment
	e.  fear of violence
	f.  inadequate income
	g.  responsibility of others
	h.   high visibility
	i.  physical strain
	j.  physical contamination
	k.  threat of arrest
	l.  stigma
	m.  humiliation
	n.  lack of respect or recognition
	o.  other: ____________________________________________

17.  How would you categorize your background?
	a. rural
	b.  urban
	c.  working-class
	d.  poor
	e.  middle-class
	f.  financially secure
	g.  upper-class
	h.  financially struggling
	i.  other: ___________________________________

18.  What was the highest grade you completed in school?
	________________________________________________

19.  Other than schooling, any other training obtained?
	________________________________________________

Appendix 2
Participatory Action Research Design (adapted from Chataway, 1997, pg. 753)
information gathering

action steps					         	problem definition
(individual use of new			                     (research questions)
skills and language,
dialogue group)

collective interpretation				instrument design
of results							(interview schedule, 
(written summaries, 					dialogue group agenda)
group discussions,
feedback on papers
for publication)

data collection
(interviews, questionnaires,
focus groups, dialogue groups)

Appendix 3

Excerpt from transcript, Phnom Penh Beer Hall, Tape 5, Feb. 22-23, 2000 

IL: Okay, so you were just saying about how some of these girls are sold..different stories, yeah.

BG: Yes. One is the pimp...uh..the lady pimp from the city. She went back to her hometown, and talked to the uh..pretty girl..young girl over there. She said okay. In the city she came help to find work and everything. And then..you know uh..tell her lie story about [?] to actually get her come to the city with her. (Uhhum) And then, send to the uh..brothel..you know uh..(yes, brothel)..brothel uh..place for so much money and she just walk away and the lady had..because [?] she pick up the money--three, four hundred dollars, and then the girl stay with the uh..place there, and then they will force her by torturing her to sleep with the customer, to..for..because they had to sell that uh..(yes)..virginity to [?] the money. That one. Another one is uh..a friend. Like the girl that been uh..in the city and she uh..come here and then find a way to uh..go back. Ask a friend to come back and sell virginity, then she take benefit out of it. Like okay uhm...we sell for five hundred, she took [???????????????] ladies take the rest like that. And uh... One thing that I come to meet this way too, because she is a city girl, I mean a country girl, and the man, the mom, the parents going to give her to get married with and..with a man that [?] gain any money. (I see. Okay). And so she’s asked a relative to uh..come here and to sell her virginity and after, a week later, she go back later and get married to that man.

IL: I see. So she has money for that one week. In that one week, she earns enough money for her doweries. Uh-hum. 

BG: Yeah so.. It’s that way too. And the rest, that’s that’s.. And then become..she becomes a prostitute, or she can get out from that and she will become the beer girl and everything like that that I mentioned last time (yeah, that’s right). The divorced girl, or..get uh..get uh..taken away from the boyfriend and everything and she lost her virginity with the boyfriend and everything.. So, she became a beer girl. But mainly right now, if you are selling percentage-wise, the married with one child and divorced because the man get away, cannot afford all because..he uh..have..has uh..many girls that she finds out, so she just..so she just divorce him. Or sometimes, the man get drunk and uh..torture her, or I mean bang..uh..beating her and everything (yes), so she run away or divorce him. So those are several story there that happen to the young girl in..uh..

Appendix 4
Beer Girl Focus Group Questions, February 2002

1.  How old are you?
2.  What company do you work for?
3.  What is your marital status?
4.  How long have you been a Beer girl?
5.  Where are you from?
6.  Have you received any training or health testing through your company?
7.  What is your education level?
8.  Can you speak English or read?
9.  If you were given the opportunity, would you like to learn either or both of
     English or reading?
10.  Have you attended the Rose Centre?
11.  What was your previous occupation?
12.  What are your future ambitions?
13.  Do you have a family/children to support?
14.  How and why did you become a Beer girl?
15.  Do you think that there is an overall negative view (stigma) of Beer girls within
       your community?  Do you feel negatively affected by this?
16.  Are you aware of any individuals or organizations within the community
       where you can go for support or advice?  What about outside of your
       community (i.e., in Phnom Penh)?
17.  Where do you receive support from? (Family, friends, other Beer girls?)
18.  Do you feel as though you receive an adequate level of support from these
       sources?
19.  Who or where else would you like to receive support from?
20.  How often do you go home with clients?  How often do you use condoms
       with clients?
21.  Do you have a boyfriend or lover?  How often do you use condoms with your
       boyfriend or lover?
22.  Do you know of any techniques for persuading men to use condoms?
23.  Do you know of any techniques to prevent yourself from getting drunk while
       still appearing to drink the beers purchased for you by your clients?
24.  Would you want to leave your occupation if there were other opportunities
       where you could make a similar amount of money?  Or would you choose to
       stay if your situation could be improved and you felt happy and safe in your
       job?  
25.  Do you have any friends who are also Beer girls?
26.  Have you ever had an STI or STD?  Any other major illness?
27.  Have you received any training about HIV/AIDS?
28.  Where do you go when you have health concerns or have illnesses?
29.  If there was an all-in-one clinic in your area where you could go for testing,
       advice, education and social support, would you attend?  If not, why not?
30.  What would you like to learn if offered additional training?
31.  Would you be interested in joining a social group for Beer girls?

Appendix 5

Excerpt from Beer Girl Data Chart 2000, 2001, 2002

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) and Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
1	Sim	ABC (Stout)	18	S	mother died of 3 diseases (typhoid, TB)	stopped in 8th gr of secondary school (because mother died)	3 mth					no	small vendor	
2	Srei Mao	Fosters	26	S			5 yr				As a group: man in hotel, 23yrs old, 2 yrs ago	boat	
3	Tir	Tiger	27	S		currently attending Rose Centre	2 yr				saw someone coming out of hospital with AIDS symptoms, woman, BG, 23 or 24 yrs old	education (currently studying at Rose Centre)	
4	Srei Li	ABC	19	S (too young)			1 yr				BG, 32yrs old, neighbour- getting skinny	no ideas	

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
5	Ra	Alain Delon	32	W (1 yr. ago)	2
m -11
f- 2		6 yr				neighbour’s husband died; wife looks ok, but it’s only been 2-3mths; widow left alone with baby	small vendor, out of home	
6	Sein Hong	Angkor (local)	32	D	m - 2yr
f- 8yr
mother		1 yr	bad reputation from people in our society
- in future want to separate from this isolation			has seen sick people, no one died, old BG who got married’s husband died 1 yr ago, has seen symptoms on BG’s skin	sell groceries out of home, raise children, education	
7	Chai	Labatts Ice	24	D, B			almost 2 yr				yes, 28yr old BG	continue training as a hair-dresser	

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
8	Neamb	Anchor
(* Spy 2002)	27
(28 in 2002)	S			5 yr				BGs died in 1996 and 1997, because of lack of education and testing	hairdres-ser, sell cloth	
9	Pich Srei	ABC	29				2 yr				girl died 1yr ago, also some young men	hairdres-ser, beautify brides	
10	Pan Sophear	Tiger
(* Spy 2002)	27
(28 in 2002)	W (battlefield death, 1992)	m - 10 yr
f - 8 yr
and mother		4 yrs	- not really friends, poverty is only commonality
- great stigma experienced, patrons try to pull her into cars, very upsetting

			saw someone		

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
11	Hout Sinan	Hein-eken	22	W (battlefield death, 1997)	f - 2 yr and parents		6 mths		those paid per case enjoy themselves much more than those on salary		no		
12	Lied Phally	Anchor	21	S	family (parents...)		5-6 mths				man who died, got skinny, family said he had typhoid but she saw his symptoms		
13	Wann Neang	ABC	25	M	f - 4 yrs
f - 6 yrs
and mother		4 mths				neighbour couple died, orphaned son		
14	Pai Nary	Stella Artois	22	S	parents		1 yr				whole family killed		
15	Srei Mien	Hein-eken	22	S	10 member family	Rose Centre	3 mths						

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
16	Lisa B. (Austrail-ia)												
17		Fosters							-No
- worked really hard, the harder you worked the more money you made				
18		Sam Miguel											
19	Heng							with other BGs criticize job, complaining, not happy to work with job like this
they don’t have opportunity, they need money					

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
20	Huor	Hein-eken											
21		Fosters	23										
22		Hein-eken	25		brother and sister, mother, grandmother, one cousin		10 mths (May 1999)					study English	
23		Hein-eken											
24	Possibly is #17 (Fosters) Cont’d	Wine and beer				was in high school last year, but didn’t finish
10 grades finished

	2 mths					upgrade herself, consid-ering Rose Centre	

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
25		Cigar-ette girl
		D (3 years)		8th grade		because of reputation classified as untouchable
		would like to work for the big hotel, but this job is looked down upon by the public
won’t get better job		English, tailor for the dress maker
- wants English so she can travel the world	
26	Som	Fosters	23				3-4mths						
27		Hein-eken	20				5 mths						
28		Hein-eken					1 year						
29		Hein-eken											
30		Fosters											
31		Alain Delon											

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
32	Tear	Tiger				family was poor, didn’t go to school							
33		Alain Delon				not good	2 yr					work in restaurant as a cook	
34	Poa	Tiger	26	B	brother	gr. 8	1.5 yr		2002	no job, no money		business in market, sell make-up	
35	Neang	ABC	24	D(W)	sister	gr. 5	2 yr			no job, no money		seller	
36	Mean	Angkor	28	D	2 children and mother 	no school	4 yr			no job/knowledge		small vendor at home	
37	Nga	Stella	32	F	parents	no school	1 yr			change		go home to village	
38	Ny	Angkor	19	S	parents and relatives	no school	3 yr			self decision		sell tablewear	

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
39	Neang	Hein-eken	22	S	sister, brother and parents	gr 4	1 yr			self decision		hairdres-ser with 7 employees	
40	Leak	Fosters	22	S	parents	gr 3	3 mth			self decision		sell cosmetics	
41	Na Vy	ABC	24	D	mother	gr. 5	2 mth			self decision		sell rice	
42	Srei	Beck	24	D		gr. 8	1 yr			didn’t know how to get other job		small vendor at home	
43	Mom	Hein-eken	23	D		gr. 4	5 mth			poverty		beauty store	
44	Boromei	Tiger	28	M	mother and sister	senior high school
gr. 12	10 mth			no job		lawyer, beauty store/hairdresser	
45	Kong	Tiger	30	D	2 children	gr. 4	5 yr			extra money			
46	Lee	Stella	29	live-in (common law)	sister	gr 2	3 mth			poverty			

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
47	Meng Li	Angkor	32	D	2 children		1 mth			no job/money			
48	Chea Ta	Fosters	19	S	brother	low grade level		BGs talk together about not wanting to be BGs				nurse, doctor	
49	Sauy	Angkor	20	S	1 child, 2 yrs old				- Fosters BGs all want to be with Heineken so can sell out
- can’t sell enough beer, wants to be on salary			small vendor	
50	Pom	Singha			2 childrenand mother								
51	Chet	Hein-eken	21	B				yes, all poor, moved around with no choice					

BG #	
BG Name	
Beer Co.	1	3	7 and 9	13	24	83 and 77	72 and 73	78	66	17	
			Age	Marital Status (S= single, M= married, F= fiancee, W= widowed, D= divorced, B= boyfriend)	Children (#, age, sex) Family Members Supported	Education level/
location	How long as BG?	Social Position Friends and Stigma/
Reputation	High turn-over rate and Feelings about job	Other occupational options, why chose job	Know/hear/
see someone with/dying from HIV/AIDS	Future Hopes	
52		ABC					1 mth						
53	Horm	Fosters	21	S	mother		1 mth					tailor	
54	Mao	Carls-berg		D	1 son	gr. 7		new, so not yet	doesn’t like it, has no choice			seller	

Appendix 6

Initial Evaluation Form for the Beer Girl Peer Educator Workshop, May 2002

Evaluation of the Peer Educator Workshops

1. Name: 
2. Age : 
3. Occupation : 

4. Please rate the following		Very Poor    		          		Very Good
1. Talk on statistics on 		1    2    3    4    5    6    7    8    9    10
	    HIV/AIDS/STDs in Siem Reap	
	2. Talk on signs and			1    2    3    4    5    6    7    8    9    10
	    symptoms of STDs
	3. Comic booklet			1    2    3    4    5    6    7    8    9    10
4. Cassette				1    2    3    4    5    6    7    8    9    10
	5. Role play				1    2    3    4    5    6    7    8    9    10
	6. Flip chart				1    2    3    4    5    6    7    8    9    10
	7. Peer training manual		1    2    3    4    5    6    7    8    9    10
	8. Practical demonstration		1    2    3    4    5    6    7    8    9    10
	    of condom use
	9. Question and answer		1    2    3    4    5    6    7    8    9    10
	    dialogue session
	10. Small group discussion		1    2    3    4    5    6    7    8    9    10

5. Any other comments/suggestions to improve the workshop:

Appendix 7

Post Peer Education Session Interview Questions, July 2002

1. Who were your friends before?
2. Who are your friends now?
3. Who have you taught (how many)?
4. Problems encountered in teaching?
5. Have you been able to use your new skills in your own life?
6.  What has changed?
7.  Materials: easy to use?  Able to use all of them?  Find some more helpful or relevant than others?
8.  Supervisors: easy to meet with?  Easy to obtain more materials?
9. Journal: easy to remember to record events?  Why?  Why not?
10. Assess knowledge now: use of condoms both with paying partners and boyfriends?
11. Problem teaching women who have been Beer girls longer than you? (Due to difference in experience level)
12.  How did you feel you were received during training sessions?  What difficulties did you face?  Were you received differently by women who were a different age than you, or who worked for a different company?

Appendix 8

Post Intervention Interview Data, July 2002

	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia	
friends- before vs. after	3 more	1 new friend, hires the room close to her	3 new friends		3 people	1	yes	
because workshop	because teaching, taught BG @ other restaurant		after workshop		after workshop	after taught her
- friend curious, wants to come and learn	other BGs at workshop	
teach how many people	10	1, the new friend, gave cassette, asked her to listen to it
- didn’t really teach, but gave cassette
- told her about lesson from workshop, listened together, discussed
- told her about what was told, giving lesson, tried to convince her to listen

	3 people: 1 man, 2 women
- man: worked in hotel
- women: BGs (Fosters and Angkor)
	tried to teach one person + her youngest brother and other relative	2 BGs, were a little bit younger	2 BGs and neighbour	BG and neighbour (2)	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia	

problems in teaching	- not easy to understand for students, do not want to pay attention to her
- problems with the concepts and language
- problem with self: not well educated, when students ask questions cannot provide feedback, hesitates because unsure		- questions are repeated (i.e. transmission from mosquito bite, “passing” the disease and not having it anymore)
- problems in teaching because of her ability	- can explain to everybody, but not everybody respect her because they are the same capacity/ability, so sometimes they don’t respect the explanation	- doesn’t find any difficulty, just asking for material to read, looking for understanding	- no problems	- 	
materials- best? problems?	No difficulty with material
- cassette player broken	- flipchart best, because wanted to know more about STDs, chart convince her to comply with hygiene standards, reading and looking at it	- all materials good for her, useful and helpful
- like to play role play (BG, fiancee, wife, drunk in restaurant)
	- all of it	- cassette	- no cassette player, wants private one, neighbour and friends want to listen to the tape she gave them, but have no player
- comic book and manual best

		
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia	
use info in own life, good for own life	yes, information good for own life	- a lot of lessons, understood
- knows how to protect self, manage her partner, convince or persuade the man who would like to go with her		- useful, practical, follows all lessons from material	- yes, practice	- yes, use with men		
changed own behaviour	- yes, changed a lot of behaviours			- explain to partner to use condoms because he’s still young and has such a long future, so if I have AIDS and give to you what do you think?
- all men she explained to this way agreed to use condoms			yes, afraid of HIV	
safe/
unsafe, 100%?	Yes, understood, useful lessons and material to join training course	100% condom use	100% changed own behaviour	100% condom compliance	100%	100%	conceded to use condoms 100%, regularly, to take care of self

	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
what do different now then before workshop	- changed a lot, struggle through life, that’s why find another job, to change her life		- after workshop understood completely and very scared to get HIV
- goes to Mondol Moi for testing (often)					
problems with using information		partner wouldn’t use honeymoon brand, had one which was more expensive, but not everyone does that
- the condom is 100 for $1, he had 1 for $1 condom
- some men protect themselves very well, wealthy families or well educated know how to protect themselves						
journal helpful	- useful and helpful
- wrote down questions which arose during teaching that she couldn’t answer
r		- yes, good journal			- didn’t count how many, didn’t write it down	- wrote both students in journal	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
Tra Tim- get materials?  Good system?	- hasn’t asked for anything yet
- training course @ AIDS sector, got more materials
- doesn’t haven enough cassettes	- hasn’t needed anything 

- attended government session, learned about women’s condoms
- showed them how to use it, but they’re very expensive, have to buy from Bangkok
- other workshop also gave booklets about how to protect themselves when alcohol is involved	- yes, very good, TT open	- not really talked to TT

- at government session had more lessons, experience and knowledge about how to persuade her partner to use condoms	- government session turn out really good even though they started early			

feel accepted at workshop		went to both sessions
- did not pay attention to MW because felt very shy, didn’t want to hear about the name of the BG because she was shy
- now it’s ok for her			- no problems, very accepted	- very comfortable, recognize other people	skipped because late	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
difficult to teach older or younger women	- older easier to teach, younger difficult		- older easier, because love their children, that’s why they pay attention to explanation

don’t tell her she’s too young?
- saw her material so trust that she’s been in training, but asked questions about where she got the material and which organization	- at beginning hard to stimulate people to agree with what she explained, but later on they agreed				
teaching BG from own co. easier than teaching anyone?
Men vs. women?	- no, not in own company, just teaching her friends, any BG she knows, any neighbour
- MW who she knows is interested in education in an HIV/AIDS program		- didn’t find any difficulty, was comfortable	- men easier than women		- tries to explain during breaks to the male construction workers
- travel through countryside, so distributes condoms, explains to protect self, tries to scare and intimidate so they’ll use
	- lots of men, not women ask for information, able to teach men, they listen	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
ideographic-hic	- has another job, daytime sells food @ market, new salary from owner
- not as much time to be a teacher
- wake up in early morning, go to market, prepare breakfast; at 2 take shower, get dressed- work all day long to earn money	asked how like job (prev. meeting she was new to job)
- now it’s very comfortable for her, knows how to get condom; realizes that and understands to 100% condom use program

sending $ for children?
- yes, takes good care of child and whole family

teach other BGs in restaurant?
- cannot be a teacher, not a teacher, will assist another teacher, can be a reader and friend and discuss	- sells porridge from her home
how was it to teach a man?
- man who roomed near her, listening when she talks to her children, understands about HIV/AIDS because listen and read to what they brought from school
- the feedback from her children has been caught by somebody else, he came out and asked her questions, asked her to teach him, explain to him, after he understand, he captured individual lessons	when upset who talks to? Support group?
Radio cassette player, doesn’t expect people to help her, listens to special song she selected herself
- keeps secret, doesn’t speak to family, try to release it by listening to song
- doesn’t want to tell friends, wants to keep it to herself
- difficult to talk to counsellors (OB and TT) because sometimes its problems in the family so cannot tell those people, only the HIV/AIDS problems

		asked how like job (prev. meeting she was new to job)
- used to it now, very comfortable
- whispers to new girls to take care of self because HIV is spreading, should be strong and tough

think women who came to workshop can now use condoms with their own boyfriends?
- expects everybody would have ability to persuade for 100% condom use

	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	

ideographic-hic II			the man had heard about HIV/AIDS for so long but didn’t believe it until he heard specific example or explanation, so the material she got at the workshop
- rumour in country that expect AIDS to be like syphilis, but later on people got killed by the symptoms of the virus, now people start to follow the symptom of a man
- man regrets not joining the lesson at the Salina

- jealous because brought tape cassette player to Neamb

	- doesn’t want to talk to counsellor, she’s struggling through doesn’t want to trouble other people, let them help her
- if friend has problem/trouble she listens but there is no one to help her
		wear t-shirt?
- wears at construction job
- most of her friends don’t ask for t-shirt, embarrassed to ask for more		

	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
questions	- other people’s questions
- neighbour too shy to go to doctor, too sick to be moved
- rumour of cure for HIV/AIDS, tree medicine, traditional medicine	- man who was “serious” with disease but did not tell her what he had, after cure complexion changed from light (yellow) to dark		- if she was HIV+ and man slept with her without condom would she still have AIDS
- told friend that he’d have it and she’d have it still			- when wearing t-shirt ask “are you a teacher of HIV/AIDS?”
- lots of people are very curious	
know anyone who died from AIDS	- friend who died, husband already died, 1 son with no AIDS, 3 yrs old, tested already
- before medicine comes to country, AIDS might kill other people			- heard about BG thrown by landlady out on the road on the way to Angkor Wat
- transmitted by her husband
- didn’t know her

upset when BG dies?
Upset and afraid, if tried 100% condom use might be safe	didn’t know Fosters girl	- saw people in career get killed, but not her friends yet

- last couple of days, Foster’s girl (Wy)
- police asked about her background, when found no family cremated her
- didn’t know her, but some of her friends had provided food and milk for the girl
- no ceremony because no family	didn’t hear about anyone dying	
	Neamb	Mao	Sophear	Mean	Ly	Pom	Mia 	
benefits of workshop			trusts herself that she can teach, afraid for future when children grow up that she might try to change herself to work to make more money to take care of her children					

Appendix 9

Steps for the initiation and maintenance of grassroots movements (adapted from Bettencourt, 1996, pg. 217-218)

1.  Emphasize the personal relevancy of an issue and foster critical awareness
	• individuals are more likely to be committed to an effort if they see that
	  the issue is relevant in their lives

2.  Create a structure that allows systematic coordination and strategic planning
	• set long and short term goals, monitor progress on each goal
	• groups should identify issues, define issues in concrete terms, develop
	  specific goals, outline flexible strategies to achieve goals, and involve a
	  sufficient number of people			

3.  Foster shared leadership and develop leadership skills among the
     membership
	• sharing leadership roles and decision-making responsibilities is
	  fundamental to keeping volunteers engaged  

4.  Foster democratic and inclusive styles of decision making and respect for
     diverse viewpoints
	• encourage open-minded thinking about relevant issues, and encourage
	  expression of minority opinions

5.  Foster group cohesion and ingroup identification
	• members more likely to persist in their activism if they feel a social
	  connection and loyalty to other group members
	• if group members become a part of how individuals define themselves
	  they are more likely to contribute to the maintenance of the group

6.  Build group and individual efficacy through skill building
	• group more effective when individual members are allowed to contribute
	  a variety of skills
	• skill development may include interpersonal communication, group
	  participation, and technological skills
	• skill development will enhance feelings of self-efficacy in group
	  members, as well as increase group effectiveness

7.  Use the member’s skills and time effectively
	• members will be more satisfied when they believe their skills are being
	  utilized and challenged, but also if they believe their time expenditure
	  has led to identifiable accomplishments

8.  Access community resources
	• communities are likely to have many resources that can facilitate
	  progress towards grassroots goals

9.  Develop intergroup coalitions
	• other groups may have important information or material resources that
	  can be exchanged
	• coalitions among several groups may sometimes be more effective than
	  single groups in achieving social change
	• establish connections with powerful persons and groups

10.  Emphasize short-term successes of the group and the successes of groups
       with similar goals
	• fuel motivation of group members to sustain their efforts by emphasizing
	  short-term successes and through learning about the struggles and
	  successes of other groups

Table 1

Martial Status of 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	AR Sample (N=35)	MM Sample (N=35)	Combined Sample (N=70)	
Single	14 (40%)	11 (31.4%) 	25 (35.7%)	
Divorced	11 (31.4%)	8 (22.9%) 	19 (27.1%)	
Widowed	3  (8.6%)	6 (17.1%)	9 (12.9%)	
Married	2 (5.7%)	8 (22.9%)	10 (14.3%)	
Engaged	1 (2.9%)		1 (1.4%)	
Live-in boyfriend	1 (2.9%)	2 (5.7%)	3 (4.3%)	
Boyfriend	3 (8.6%)		3 (4.3%)	

Table 2

Education levels attained for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	Low/not good/none	Primary	Secondary	No. responding	
AR Sample	6 (30%)	7 (35%)	7 (35%)	20	
MM Sample	7 (20.6%)	13 (38.2%)	14 (41.2%)	34	
Combined Samples	13 (24.1 %)	20 (37%) 	21 (38.9%)	54	

						

Table 3

Condom use reported by 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	Paying Partner	Non-Paying Partner	
Everytime	20 (67%)	1 (5.8%)	
More than half the time	6 (20%)	3 (16.7%)	
About half the time	2 (6.7%)	2 (11.1%)	
Never	2 (6.7%)	10 (55.5%)	
N/A		 1 (5.8%)	

Table 4

AIDS/STD Risk Perception for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	None	Low	Quite high	High	Don’t know	No. responses	
Own chance of having AIDS/STD	5 (14.7%)	13 (38.2%)	11 (32.4%)	5 (14.7%)		34	
Most recent partner’s chance of having AIDS/STD	7 (26.9%)	7 (26.9%)	7(26.9)		5 (19.2%)	26	

Table 5

Knowledge of HIV/AIDS for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	Yes	No	Don’t know	No. responses	
Heard of HIV or disease called AIDS?	34(97.1%)	1 (2.9%)		35	
Know someone who has died of HIV/AIDS?	10 (28.6%)	25 (71.4%)		35	
Protect self from HIV by using condom correctly everytime you have sex?	2 (6.1%)	1 (3%)	30 (90.9%)	33	
Can a healthy looking person be infected with HIV?	17 (48.6%)	1 (2.9%)	17 (48.6%)	35	
Can AIDS be cured?	2 (6%)	33 (94%)		35	

Table 6

Sources of Information about HIV/AIDS for 35 Indirect Sex Workers at Mondol Moi Health Centre- May-July,2002
	Where heard about need to use condoms to protect self? (More than one answer possible.)	Main source of information about AIDS? (More than one answer possible.)
	
Television	27 (77%)	12 (35.3%)	
Radio	22 (63%)	9 (26.5%)	
Newspapers	1  ( 3%)	0	
Friends	4 (11.4%) 	2 (5.9%)	
Husband	3 (8.6%)	1 (2.9%)	
Boyfriend	2 (5.7%)	1 (2.9%)	
Client	0	0	
Siem Reap NGO	6 (17.1%)	4 (11.8%)	
Other sources	9 (25.7%)	5 (14.7%)	

Acknowledgements

I would like to thank Dr. Ian Lubek for his guidance and critical eye, Jamie Amodeo and Barb Lovitt for their “big picture” vision, Dr. Mee Lian Wong for her empirical support, Maryan Chhit and Savoen Touch for their data gathering, the University of Guelph and the Elton John AIDS Foundation for supporting the project, Vanna Mok for translations and cultural guidance, and various research assistants for preparation, translation and analysis of materials: (Paris) Bab-Rethba; (Singapore): Kenglee Chew,  Teck Ngee Lee, Khieng So Chivy, Chheng Sim, and Seng Sophea; (Guelph) Dallas Giroux, Stephanie Collins, Sandra Dixon, Tara Hannah, Heidi Lund, Kathryn McDonough,  Jennifer Hieminga, Liz Branco, Cyril Arfeuille, Allison McNeil and Danielle Stevanov; (Cambodia)  Sok Huor Chea, Som Sophal, Ou Bory, Dr. Uy Borany, and  Tra Tim;  (Australia) Sovannairand Kay and the members of the translation team of the Khmer Community of New South Wales, Inc.