7.1  Assessing needs What is the situation? Who should be involved? What are the sexual health needs? What sexual services are practised? How is sex work organised? What STD services are used? Do services and projects already exist? What policies do services have? What is the legal context? 7.2  Assessment techniques Gathering existing information Collecting new information 7.3  Project planning and design Making sense of the problems Turning problems into objectives Activities Measuring change Identifying assumptions 7.4  Monitoring and evaluation Is the project working? Monitoring Start at the beginning Types of evaluation 7.5  Project planning: an exercise

  
Sex worker participation 
The participation of sex workers is essential for a needs assessment to be meaningful. Generally, the earlier sex workers become involved, the more useful the result will be. Projects need to be flexible to allow sex workers to participate. For example, sex workers may need training to conduct interviews or participate in planning committees. Times and places of meetings need to be convenient for sex workers. The style of meetings must not be alienating. For example, project management jargon should be minimised and explained. Even very technical discussions can be accessible to observers.

Setting the scope 
It is important to set the scope of a needs assessment so that the information gathered answers key questions. For example:
 

	Who is involved in sex work directly or indirectly, and who should be reached?
	What social and legal contexts, practices, knowledge and beliefs help or hinder safe sex?
	Where does sex work take place and consequently where should activities be focused?
	When is it most convenient for sex workers to be contacted or attend clinics, workshops etc?
	What do sex workers want?

The answers to these questions will help to identify what type of activities are most appropriate.

The first step in planning a needs assessment is to decide the "big questions", that is, those which underlie the purpose of the needs assessment. Then divide each of the "big questions" into a number of smaller questions. For example, to answer a big question like this: Is a health project necessary in this area?

Ask some smaller ones like these:  
What other services exist and what do they do? 
Are sex workers accessing appropriate health care? 
Are sex workers and clients practising safe sex?

To answer these big questions: 
What type of service would be most effective? 
Who should deliver it? 
Who should be targeted? 
What obstacles are there?

... ask smaller questions: 
How useful would written materials be? 
If they are not likely to be useful, what alternatives might be useful? 
Is there any potential for working with clients or influencers? How might that work? 
Should women, men and transgender sex workers be included or should any project only target one gender? 
Would peer education be appropriate? How might peer educators be recruited and trained? 
Should the project specifically target sex workers or should it target sex workers as part of a broader audience? 
What geographic and demographic factors affect the capacity of the project to reach sex workers?

The process continues until a question emerges that can be answered. For example, to answer: Would peer education be appropriate?

Ask: Are sex workers suspicious of authorities? 
Is there much rivalry among sex workers? 
Is there a single "underground" culture or are there more than one? 
What is the mix of ethnic and language groups?

Then... 

Look at how peer education works in similar situations. 

Discuss the possibilities for peer education with potential peer educators, influencers (especially sex business managers) and other sex workers.

 
 

A project planning meeting in the Philippines. Planning and evaluation should be accessible to everyone involved. A research project was asking things like: “How many abortions have you had?” “What religion are your parents?” “At what age did you first have sex?” There was nothing which explored what magazines and newspapers sex workers read, where they got their information about HIV/AIDS/STDs or what other languages they spoke. It was a confused mix of pseudo-scientific, quasi-anthropological enquiry rather than a solid base of information which leads to action. Consultant. France

Who should be involved? 
The needs assessment needs to involve a range of people.

Sex workers 
 

	Where do most sex workers come from?
	What movement is there of women and men in and out of sex work?
	Are there any networks or associations of sex workers or relevant sexual minority groups, such as gay men or transsexuals. If so, what do those organisations do?
	Are there possibilities for collaboration between the project and sex worker groups or other
	agencies?
	What ethnic, religious, language or caste groups do sex workers belong to?
	Do male sex workers identify as gay, bisexual or heterosexual? What links do they have to gay communities?
	Do sex workers take drugs? If so, which ones and what is their impact?

Clients 
 

	How can clients be grouped? For example, local single men, local married men, migrant labourers, truck drivers, tourists, military men, men who identify as gay? Do groups vary in each sex work location?
	What languages do clients speak?
	Have clients been targeted by general health education campaigns? What is their understanding of sexual health?

Influencers 
 

	What tasks are performed by people who do not directly provide sexual services, e. g. finding or greeting clients, providing premises, cleaning, serving drinks or food, protecting sex workers from violence etc?
	What are the priorities and interests of these people?
	What are the similarities and differences between their priorities and those of the sex workers?
	How do influencers relate to sex workers, clients and to each other? Is there any rivalry or violence? Are there associations of sex business owners or other ways to address them collectively?
	What languages do influencers speak?

There are a range of people who have an important influence on how the sex industry is conducted. Only the most informal sex work does not involve "influencers". Some business managers are helpful while others are not. Some local business people and even police are helpful, while some obstruct the objectives of health projects.

People who perform different tasks in the sex industry can be grouped in various ways. Groupings should not be used to prejudge them according to stereotypes or moral values. Some examples are:
 
Private influencers 
 

	sex workers' families
	lovers (of women and men)
	other "street people", including people with whom sex workers share accommodation, drug dealers, performers, members of sexual subcultures, friends, neighbours etc.

Business influencers 
 

	landlords, bar and cafe managers and others who allow their premises to be used for commercial sex
	managers of brothels, bars, escort agencies and other formal sex businesses where sex workers work
	taxi drivers, nightclub staff, advertisers and others who are paid to facilitate meetings between clients and sex workers.

Professional influencers 
 

	police and other law enforcement agencies
	doctors, health and social workers, counsellors, outreach workers
	politicians and other policy makers.

"We used a number of methods to evaluate our project: Formative evaluation  At the beginning of the project we used focus groups, individual interviews and observation to learn more about the commercial sex workers in Calabar and design the specifics of our intervention. Process evaluation  Project records provided us with information about educational sessions in the hotels and clinic, chairladies and proprietor's meetings held, condoms given away free and sold and clinic attendance. Outcome evaluation  At the beginning of the project we used a questionnaire to collect data on STDs/AIDS knowledge, sexual practices and condom use. We used serology (blood tests) to determine the prevalence of HIV and other STDs and noted changes over time. Registration and attendance at the clinic provided us with a means to measure awareness of the existence of the clinic and understanding of the need to treat STDs and other ailments at the clinic. For example, at the start of the project 60 per cent of the women took antibiotics as a prophylaxis for STDs. Now, most of them rely on the clinic to treat their health problems. Qualitative information collected through observation and focus group discussion demonstrated the enthusiasm of the target population for the programme. Feedback from the larger community, observations pertaining to the behaviour and response of the target group to the programme and overt official support and recognition of the programme represent significant ways of evaluating programme acceptability and effectiveness." The evaluation framework of a project in Calabar. Nigeria.

  
Wider community 
 

	religious or cultural leaders
	local community groups.

What are the sexual health needs?
 

	What is the relative importance of different STD and HIV transmission routes, such as male-to-male sexual contact, male-to-female sexual contact, mother to child or drug injecting using shared needles or syringes?
	What is known about patterns of HIV and STD infection among female and male sex workers, and among other groups (e. g. truck drivers and transport workers, military men, drug injectors, and those attending STD clinics and antenatal clinics)?
	What information is available about STDs, reproductive health and HIV for different population groups?

What sexual services are practised? 
 

	What kinds of sex are practised by sex workers and their clients, whether women, men or transgender people?
	Do sex practices vary according to type of contact or transaction site (e. g. between bar, brothel and street based sex work) and/or geographical region (different parts of a city or country)?
	Do sex practices (and safe sex) vary with different types of clients and partners?
	How much does the process vary between different services?
	Are people familiar with condoms?
	What are people's attitudes to condom use?
	Where are condoms available and at what cost (and how does the cost of condoms compare with the cost of sex)?
	Are lubricants available and are they used?
	In which situations are condoms more or less likely to be used and why?
	Are other contraceptives used?
	What, if any, myths or misinformation exist?

How is sex work organised? 

Arrangement 
 

	contact sites (e. g. bars, clubs, brothels, neighbourhoods. hotels, street, through newspaper advertisements)
	transaction sites (e. g. brothels, hotels, rooms near bars, sex workers' apartments/private rooms, car parks)
	level of control by influencers
	sex workers' freedom of movement
	existing community organisations (e. g. formal or informal networks of sex workers, sex workers' or gay organisations) and any services they provide (e. g. child care, legal assistance, support groups, credit union)?

Location 
 

	Where does sex work occur?
	Where are those who influence the sex industry located?
	Where do most clients come from?
	Where are law enforcement agencies located (e. g. police)?
	Where are condom distribution points, and health and welfare services?

Working conditions 
 

	What is the balance of power between sex workers and clients and between sex workers and business owners and managers?
	Does the balance of power vary according to contact/transaction site, age of sex workers, economic level of the establishment and/or the client?
	To what extent can sex workers choose or turn down clients who are abusive, drunk, or refuse to use condoms?
	Is there access to running water, clean linen, and adequate safe sex supplies (condoms, lubricant)?
	Can sex workers communicate freely with each other?
	What other health and safety issues affect sex workers. e. g. compulsory alcohol consumption, incidence of hepatitis, tuberculosis or dermatological conditions or violence?

What STD services are used? 
 

	What STD services are available?
	Are services good quality?
	Are services welcoming to female/male/transgender sex workers? Have staff been appropriately trained to deal with marginalised people?
	What symptoms do sex workers recognise as suggesting an STD?
	What level of pain or discomfort is considered normal (e. g. itching, abdominal pain, backache)?
	Do sex workers examine clients for signs of infection (e. g. penile discharge, lesions, warts)?
	Do sex workers use any medications other than those prescribed by doctors?
	What do sex workers do if they feel ill or uncomfortable? Who or where do they go first for advice (e.g. clinic or private doctor, family member, friend, business associate or manager, traditional healer, informal drug vendor, pharmacy)?
	Are there specialised STD or AIDS clinics or are STD services provided in other settings such as hospitals or family planning clinics?
	Are services available at a convenient time and place?
	Do people feel stigmatised by using services?
	Does the cost of services affect whether people use them?

  
Do services and projects already exist? 
 

	What relevant health promotion or social welfare programmes already exist, either at local or national level, such as targeted education (e. g. to men who have sex with men), condom promotion or self-help groups?
	Are there already any sex work projects, either specifically for sex workers or including significant numbers of sex workers as part of a larger target group, for example health projects or charitable work?
	What activities are these projects promoting?
	What problems or constraints have been identified and how have they been resolved (e. g. police confiscating condoms, high rates of migration among sex workers and/or clients, unwillingness of sex workers to participate, high rates of condom breakage, unreliable distribution of condoms or other necessary materials)?

What policies do services have?
 

	Are sex workers required to undergo regular examinations for HIV or other STDs? If so, how often and in what circumstances?
	What are the consequences (legal, job-related) of having (or not having) HIV and STD tests?
	What are the consequences (legal, job-related) of testing positive for HIV or another STD?
	Do the same regulations apply to both women and men who sell sexual services?
	How do sex workers and clinical staff feel about local STD policy?
	Do services already incorporate health education?

What is the legal context? 
 

	What laws affect the sex industry, either directly or indirectly? (See Chapter 2.)
	Do the same laws and regulations apply to women, men and transgender people? If not, what are the differences?
	Are sex work businesses and activities, such as brothels, known street areas, massage parlours and commercial sex bars and clubs, legal or illegal? If they are illegal, how do they operate - through tolerance, corruption, weak laws or inadequate resources to enforce the law?
	What penalties exist (e. g. fines, jail, deportation) and against whom are they used?
	Do sex workers avoid STD services because they are associated with police or other authorities?
	Are laws against rape and physical assault enforced when sex workers are the victims?
	How do police and other law enforcement agencies respond when sex workers report crimes in which they are the victims?

7.2 Assessment techniques

Focus groups can be an ideal way to gather information upon which to base plants to diversify or refine a service.

  
Gathering existing information 
Information about sex work and the HIV/STD situation, and the social, economic, cultural, religious and legal contexts in which sex work occurs, may be collected from:
 

	articles about the sex industry in local newspapers and magazines
	novels and short stories by local writers that contain sex workers as characters and which describe the context and/or practices of commercial sex
	memoirs and other first person accounts by sex workers and/or clients
	epidemiological and sociological studies, information about relevant behaviours and practices (e.g. in HIV/STDs, gender and sexuality)
	international publications and resource centres listed at the end of this book.

Collecting new information 
The first section in this chapter suggested key questions which might be used to investigate the local sex industry. Informal methods of gathering information about stigmatised and intimate behaviours, such as observation and key informant interviews, (with those who are knowledgeable "insiders") are usually more effective than formal surveys. It is extremely useful to train sex workers themselves as interviewers and observers. 

Mapping 
It can be very helpful to produce a "map" of the local sex industry. based on existing maps of the area in which work is being planned. to identify the key issues for the project to address.

Sex workers often know a great deal about sex work in the area and can be important sources of information for mapping. A map could show:
 

	where sex workers and clients meet each other
	where sex workers and clients have sex
	where agencies that provide services to sex workers, clients are located
	where important events such as police activity and festivals take place (and when)
	location of condom distribution points, health and welfare services.

As with any documentation of commercial sexual activities it is essential to prevent any misuse of such a map. The map should be treated as confidential.

Estimating population size 
It is useful to have some idea, however approximate, of the size of the target group. This helps in identifying activities and locations for your work and in setting targets. Preliminary estimates are often too low, as they are likely to be based on the more visible forms and locations of the sex industry, and may not take into account either the amount of clandestine sex work (e. g. male or transgender sex workers) or the impact of migration. However, estimates can be revised as the project develops. 

In any country, there are usually both female and male sex workers. In some countries, there are also transgender sex workers. There are usually more female than male, but very rarely are there no male sex workers. Male and transgender sex workers tend to work in the same way as females but in different locations. Adult and adolescent sex workers may be working separately and have different needs (young people are more likely to provide sexual services informally or occasionally - street youth may trade sex for food or a place to sleep, for example).

Counting sex workers and clients is an important feature of needs assessment, although the result is unlikely to be exact and does not need to be. Some forms of sex work are easily observable while others are not. To estimate the size of a commercial sex market which includes closed clubs, bars and private homes, researchers must have access to basic information which can only be provided by "insiders". There is a case for beginning pilot services while gathering information on which to base a long-term strategy.

Estimating the number of clients can be dealt with similarly. A survey of sex workers and interviews with a random sample of each category of sex worker could help determine how many clients there are on a typical night, types of clients and how many visits clients make per week or per month.

Surveys and interviews with sex workers could also show how many clients are casual (new to them), how many are seen regularly. how many are frequent clients (even if new to them personally) and how many are rare clients. Again, this approach might be more successful once some level of service has been started and contact with sex workers established.

7.3 Project planning and design

Making sense of the problems 
Every project needs a clear vision of how to solve the main problems identified in the needs assessment. It can be useful to write each problem on a card. Take each card and ask, "What causes this problem?" Write the answer on a second card, and place it underneath the first. Go through the problems in this way until they have each been linked to a cause.

 
 

Consultants from donor and technical support agencies can participate in projecting planning and developing evaluation systems rather than imposing their systems and methods

Turning problems into objectives 
The next step is to imagine an ideal situation which would solve all the problems you have identified.

Summarise this situation. For example. "Sex workers and others are able to work in safe, health promoting conditions." This becomes the overall goal or aim of your project. However, your project probably won't achieve this alone, so it is important to state clearly how your project will contribute to this overall goal. The steps towards achieving your goal are your objectives.

For example, your needs assessment might identify a pressing need to provide sexual health services for sex workers. Objectives need to be specific, measurable, achievable, relevant and time-limited (SMART). The objective to provide health services would state how many clinics would provide what services to what standard, how many peer educators or outreach workers would promote the service and the number of workshops or training sessions that would be held - all within a specified time period.

Activities 
To achieve each objective requires about three or four key activities. These state what the project staff will actually do. Each activity needs to have a defined set of targets or results such as how many clinics will be established, what equipment secured, what materials purchased or produced, how many staff recruited and trained etc.

Measuring change 
Indicators need to be established for each activity to enable you to see where it is being carried out as planned and helping to achieve the objective. Indicators enable you to see if you are reaching your targets. Indicators are very useful for assessing the performance of the project and are essential in monitoring and evaluation (see next section).

Indicators should be worded in terms of quantity (numbers of people, infections, services, materials etc.), quality (to what standard) and time (by what date). Consider how this information will be collected and documented and ensure that project staff have the skills and resources to do this.

Identifying assumptions 
It is important to identify any assumptions that you are making. For example, you may be assuming that the level of police activity remains low, but what would happen to your project if it suddenly increased? If this is a real possibility you may need to include a relevant activity.

 
 

“When I first went to those meetings people might as well have been talking Chinese. I was terrified that they were going to ask me for an opinion and I would be exposed. I thought: “God what am I doing here? Now I know that when they say ‘monitoring and evaluation’ they just mean keeping track of what you are doing and making sure it’s working. Now I manage the project, do all the statistics and write the reports.”  Project manager, Britain

7.4 Monitoring and evaluation

Is the project working? 
There are many reasons to monitor and evaluate projects. Monitoring and evaluation takes place throughout the project and enables regular reports to be produced. Special purpose evaluations, or reviews. take place less regularly. Some are conducted internally and some involve external evaluators. Evaluation methods vary considerably and can include complex scientific measures as well as simple information gathering and analysis.

Monitoring and evaluation aim to answer key questions about two aspects of the project - the process and the impact. Key questions are:
 

	Are project activities being carried out as planned? How could they be improved?
	Is the project achieving what it set out to do, and making a real and positive difference in people's lives? How could this be strengthened further?

7.4  Monitoring and evaluation 
Evaluation is an integral part of a project. The evaluation process needs to be developed before a project is implemented so that activities can be monitored throughout the period. It is a mistake to conduct a project and "do the evaluation" later.

Sometimes evaluation is seen by project staff as a burdensome, intrusive or even threatening task. This is particularly so if the evaluation is seen as serving external needs. Evaluation developed with the participation of staff, volunteers and service users and seen by them to respond to their needs, is likely to be more effective and less difficult to implement.

Health professionals and policy makers recognise that health education, especially HIV prevention, can be hard to evaluate. The impact of the project can be difficult to measure in isolation from other factors. For example, it is difficult to know if condom use has increased as a result of a targeted intervention directed at sex workers, or as part of a general education campaign which has reached both sex workers and clients. Likewise, it is difficult to measure the extent to which peer education has reached those who would not otherwise have had access to health information.

Evaluation of a state-enforced policy of condom use in brothels (in Thailand) revealed a great success. Condom use had risen at a satisfactory rate. However, the evaluation also revealed the worrying information that the STD rate had not declined as expected. Programme planners needed to discover why this was so and refine future work accordingly.

Evaluation should: 
 

	show whether the projects' objectives are being achieved, or what progress is being made, and whether any changes are needed
	show whether resources are being used in the most effective way and how they could be better used
	involve a broad range of stakeholders to provide a picture of the project from their various perspectives. This is sometimes called "participatory evaluation",

 

In Ecuador a primary health care clinic was planned to be located in a brothel complex. A needs assessment found that sex workers wanted health care for their children as well as themselves and that they would not take their children to the brothel area. An alternative site for the clinic was found in a nearby market.

  

Monitoring 
Monitoring means regularly gathering information about the project's activities from the start to find out whether work is being carried out as planned and whether there are any reasons to change the goal. objectives or activities. Information can be collected from, for example, service users, clients, health care workers and other participants. Monitoring looks at the "reach" of the project (what percentage of its potential target group it is reaching) and includes quantitative information, such as the number of new contacts made, the number of condoms distributed or requested, and number of clinic visits or referrals made.

It is important that monitoring is an integrated, ongoing activity. Minutes of meetings, staff journals, newsletters and field notes should be routinely collected for analysis. Recording systems, such as forms and checklists, should be clear and well designed, and staff should be trained in their use.

Start at the beginning 
Effective monitoring and evaluation begins by setting measurable objectives at the outset. Progress can be monitored by asking questions. 

The measures used for monitoring progress are called indicators and these help to keep track of what the project is doing (and not doing) and where it is going.

Smaller questions can indicate the answers to the bigger ones. A common big question, is: "Has the project reduced the transmission of HIV and STDs to and from sex workers?"

It is usually neither possible nor appropriate to answer this by asking how many sex workers have AN or an STD, partly because baseline data does not exist. However, using smaller questions provides indicators which can help to answer the big question.

For example: 
 

	Have more of the sexual contacts been protected as a result of the project?
	Have there been any changes in frequency of minor STDs or unplanned pregnancies? Have requests for condoms and lubricants increased?
	Have sex workers changed their patterns of seeking health services for the better?
	Have visits to an STD clinic or private doctors increased?
	Has the project received an increase in requests for referral to doctors and clinics?
	Have any of the barriers identified in the situation assessment been addressed e. g. has training been provided for local service providers?
	Has the project reached enough workers?
	How many sex workers are in the target group? (This may have been reviewed since a previous needs assessment.)
	What percentage of the target group has been reached?
	What are the characteristics of those who have not been contacted? (Perhaps they are at great risk or perhaps they are working safely and do not need advice, support or assisted access to condoms.)

Types of evaluation 

Process evaluation 
Process evaluation focuses on how the project is implemented. It considers aspects such as: 
 

	number of training sessions/publications/events completed
	number of STD examinations performed or referrals to other services
	number of sex workers, clients and influencers contacted
	number of "one off" contacts compared with the number of repeat contacts
	average amount of time spent with members of the target audience
	percentage of meetings. events and tasks in which sex workers have participated.