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Try out PMC Labs and tell us what you think. Learn More. Anonymized databases are available from the corresponding author upon reasonable request and with permission from St. For women who want to, exiting sex work can be challenging. Numerous programs strive to help women wanting to exit sex work and secure alternative sources of income by providing targeted support at key moments during the transition, yet few of those initiatives are rigorously evaluated. We present the de of an evaluation study of Exit Doors Here which combines quantitative and qualitative methods to assess participant recruitment and retention into the program, program fidelity, and relationships with service providers process evaluationas well as progress made by participants in terms of strengthening their social support networks and moving closer to achieving their housing, pre-employment i.

Each year for 4 years, between 25 and 30 Exit Doors Here clients will be invited to complete an interviewer-administered questionnaire at the beginning and after completing the program, and to share data from their CTI charts and related documentation. Once a year, program staff and peer workers will be interviewed, and service providers will be surveyed. Conducting a formative process evaluation will allow us to inform program implementation and improve program delivery early on for maximum benefit.

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The summative outcome evaluation will provide much needed evidence on the effectiveness of CTI in supporting a traditionally underserved population to achieve the housing, pre-employment and income-related goals they value, and their progress towards reducing their involvement in, and eventually exiting, sex work. Between and in Canada, police services reported approximately 16, prostitution-related offences, making it a leading cause for law enforcement at the street level [ 1 ].

Of these, were reported in Ontario, the highest across Canada [ 2 ]. In Ontario, the majority of reported human trafficking cases, which is one of the fastest-growing crimes worldwide, involve sexual exploitation [ 3 ]. For women who want to, exiting sex work can be complicated by multi-traumatic symptoms and challenges related to addictions, physical and mental health problems, legal matters, housing issues, and lack of employment skills [ 5 — 9 ]. Existing interventions and programs that support exiting sex work may take on various forms. Residential treatment centres offer intensive time-limited psychoeducational programs targeting issues such as mental health, substace abuse or trauma [ 9111415 ], while diversion programs involve a collaboration between different community services e.

In a similar fashion, case management involves outreach workers linking their target clientele with community services including housing, mental health and substance abuse treatment services [ 10 ]. To date, very few interventions supporting women who want to exit sex work have been rigorously evaluated. Little evidence thus exists around how such interventions could be successfully implemented and how effective they might be in reaching their objectives [ 11 ].

Similarly, a secondary analysis of a US-wide evaluation of substance-use disorder treatment programs found that the provision of ancillary medical, mental health, and psychosocial e. However, the programs were not tailored to women involved specifically in sex work and their objectives were not to support their exiting process.

Diversion programs have been suggested to be a cost-effective and holistic approach to reducing sex work recidivism i. Further limitations of these evaluation studies include low retention and follow-up rates, small sample sizes, qualitative methods mainly, and weak evaluation des [ 18 ].

Our aims are to:. Exit Doors Here is funded by Public Safety Canada, the Federal department which provides policy leadership, coordination and program support to prevent crime, enforce the law and rehabilitate offenders. The program is implememented by a Toronto-based non-profit organization which works with women to create meaningful changes in their lives, avoid conflict with the law and build a sustainable livelihood. This organization has recently seen a dramatic increase in the of sex workers accessing their services for concerns surrounding legal matters, housing issues, addictions, and medical and mental health problems, and were thus favourably positioned to implement the program.

Exit Doors Here is a 9-month capacity-building program during which women who have expressed the desire to exit sex work closely work with a case manager to address one to three areas that they view as essential to their making a successful transition towards exiting. Focus areas for women who care for children or other family members include health and wellness, parenting and life skills, rent and entitlement management e. Throughout the program case managers work one-on-one with women to strengthen their support networks by connecting them with culturally-appropriate community-based service providers, peers and family members who will assume the primary role of support after the program is over.

The model has since been adapted for other populations such as victims of domestic violence [ 2122 ] and men leaving prison [ 23 ]. To our knowledge, only one research study on CTI among sex workers has ly been conducted [ 24 ].

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CTI is a time-limited intervention divided into three phases of 3 months each with decreased intensity over time Fig. Over three three-month phases, individuals work one-on-one with their case worker to co-develop a treatment plan based on their needs Phase 1try out the community supports set up for them Phase 2and see their care transferred from their CTI case manager to community services who they can work with in the long-term Phase 3.

A pre-CTI phase which has no time restriction can be built in to allow case managers to start building a rapport with their clients as they begin their transition. This model of intervention recognizes that exiting sex work is a staged process, that distinct cognitive and behavioral adjustments are needed to support behavioural change among populations facing multiple challenges, and that relapses and disengagement can occur and hinder exiting goals.

All female-identifying individuals who consider themselves either street-based, trafficked or non self-identified sex workers i.

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In keeping with the CTI model, case managers only work with a small of clients at a time. It is expected that between 25 and 30 women will enroll in Exit Doors Here each year, complete the intake process, and move on to other stages of the program, for a total of approximately to women assisted over the 5-year duration of the program — An outreach campaign targeting key public locations including public transit stations and information boards in health centres will also be performed.

A mixed-methods process and outcome evaluation will be conducted by an independent team of researchers from the MAP Centre for Urban Health Solutions at St. The following questions will be assessed:. Did participants advance their readiness to make progress on their pre-employment goals e. Did participants advance their readiness to make progress on their income-related goals? Finding a control group for this group of program participants that would avoid the problem of selection is virtually impossible.

Therefore, we use a pre-post de but will conduct a contribution analysis to strengthen the ability to make inferences about causality. A contribution analysis is a theory-based approach that can be used to infer causality based upon the contribution the program is making to the observedand to confirm or revise a theory of change.

Evidence to develop the contribution story will come from a combination of literature reviews and primary data collected among women, program staff, and partnering service providers [ 25 ]. The evaluation will access data from three groups of individuals: i women enrolled in the Exit Doors Here program; ii program staff and peers; iii partnering service providers. Enrolment in the program and the evaluation will occur on a rolling basis.

All program staff and volunteers will be invited to take part in annual semi-directed interviews. Organizations providing services and support to program staff and clients will be invited to complete an annual online survey. The study protocol has been approved by the St. Prior to data collection women will provide written or verbal informed consent, service providers will provide written consent, and program staff will provide verbal consent.

Women will be compensated for their time. A of data sources will be used as summarized in Table 1 and described in more details below. The baseline questionnaire collects socio-demographic data, information about legal issues, satisfaction, goals, and challenges related to housing, employment, education and training, and financial situations Additional file 1. A post-intervention questionnaire will be administered approximately 1 month after women graduate from the program Additional file 2. Open-ended questions will assess changes made by women to their housing, employment, education and training, and financial situations, and goals remaining to be achieved.

The Empowerment Star is deed to support and measure change, and is underpinned by a person-centred, strengths-based and co-production approach to service delivery [ 30 ]. At the beginning of each of the three CTI phases, clients rate the stage of change they feel they are at for all nine subscales of the Empowerment Star which overlap to some extent with CTI focus areas: safety, accommodation, support networks, legal issues, health and wellbeing, money, children, work and learning, and empowerment and self-esteem. The Empowerment Star is informed by the Transtheoretical Model TTM of Change which stipulates that intentional change in behaviour occurs as a process, not at a specific moment in time, and recognizes that individuals can transition back and forth between stages until they achieve stability [ 3132 ].

The Dutch adaptation of the CTI fidelity scale will provide a quantitative assessment of two dimensions of program fidelity i compliance fidelity and ii competence fidelity [ 22 ]. Compliance fidelity measures the degree to which staff are practicing the key elements of CTI. It is measured by assessing the extent to which the program is being delivered to its intended structure and with skill and attention to the CTI model.

Competence fidelity is assessed by measuring chart quality and completeness. Fidelity will be assessed in the first year of the program to provide staff with recommendations for change and improvement, and in each subsequent year for quality control purposes [ 33 ]. Every year, Exit Doors Here staff and volunteers who provide direct services to clients will be invited to take part in a 20 to min semi-structured interview conducted face-to-face or over the phone.

The interviews will help identify factors which might influence program implementation, fidelity, and outcomes, and will inform the contribution analysis. The survey includes a mix of close-ended questions on 5-point Likert scales and open-ended questions. To assess whether program recruitment strategies are effectively reaching target clients Table 1Q1data from CTI charts will be used to compare the demographic characteristics and types of sex workers street-based, trafficked, and non-identifying sex workers recruited into the program to those of the target population.

Client retention Table 1Q2 will be assessed every year and at the end of the program duration. The fidelity scale may be adapted accordingly to better reflect the context of working with women attempting to exit sex work. Following this validation step, the adapted fidelity scale will again be completed every year using data from five randomly selected participants. Item-level fidelity ratings will be interpreted in light of a 5-point rating scale: program not implemented in line with CTI model, poorly implemented, fairly implemented, well implemented, and ideally implemented [ 22 ].

Each year, interviews with program staff and volunteers will complement the interpretation of fidelity scores to identify factors that may enable or constrain high fidelity in program delivery. Subsequent adjustments may be made to the program if needed [ 23 ]. With these data we will categorize women according to whether they have progressed towards their initial goals.

This is will be complemented by post-intervention questionnaire data in which women discuss facilitators and barriers to making progress or not on their initial goals. Since exiting sex work is a process, it is unrealistic to expect that all clients will attain their long-term goal of exiting sex work within the limited timeframe of CTI.

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Helping women transition out of sex work: study protocol of a mixed-methods process and outcome evaluation of a sex work exiting program