Abstract

Background: The primary objectives of this study were to estimate the prevalence and identify the common forms of sexual harassment perpetuated by male customers against female bar workers, and investigate their association with depressive symptoms. Methods: A cross-sectional study was conducted from May to June 2017 using venue-based cluster sampling technique from a representative sample of 410 female bar workers in Yaounde, Cameroon. Depression was measured using the 5-item Mental Health Inventory (MHI-5) scale. Respondents were read a definition of what constitutes sexual harassment and asked if they had experienced one or more such behaviours from their male customers in the past 3 months. Weighted logistic regression analysis was used to examine the relationship between male customer sexual harassment and depressive symptoms. The level of statistical significance was set at p-value ≤0.05. Results: The median age of the 410 female bar workers who participated in the study was 29 years (IQR=25-34). About 41.5% (n=170) were found to have developed depressive symptoms in the past 4 weeks. The majority (98.8%) of respondents had experienced one or more forms of sexual harassment from their male customers in the past 3 months. The most common form of sexual harassment experienced was sexual advances from male customers including requesting the telephone numbers of female bar workers for them to be contacted later for a date (90.9%). After adjustment for potential confounders, respondents who experienced inappropriate starring from their male customers that made them felt uncomfortable (AOR=3.08; 95% CI, 1.90-5.01) and those who received repeated demands for a date from male customers despite their rejection (AOR=1.61; 95% CI, 1.04-2.49) were significantly more likely to have developed depressive symptoms in the past 4 weeks prior to the study. Conclusions: Male customer sexual harassment was very prevalent in this study and was associated with depressive symptoms. There is a need for interventions to reduce sexual harassment perpetuated by male customers against this group of women. It is also essential for the establishment of community-based services for the diagnosis and treatment of depressive symptoms among these women and other vulnerable population.

1. Introduction

Sexual harassment remains a widespread workplace phenomenon and a major social problem of public health significance ¹. In a recent national representative survey conducted among 2,000 individuals in the United States, 81% of women and 43% of men had experienced one or more forms of sexual harassment during their lifetime ². Although men experience sexual harassment, the prevalence is higher among women ^{3, 4}. In a study conducted among 387 female faculty members in Ethiopia, 86.3% reported to have experienced some form of sexual harassment and/or workplace abuse in the previous 12 months ⁵. A similar study in Malaysia among 1,423 females at public higher education institutions found that 52.7% reported to have experienced sexual harassment ⁶.

Numerous research have investigated workplace sexual harassment among women and most of these studies focused on harassment perpetuated by colleagues and supervisors ^{3, 4, 7, 8}. On the contrary, there are few studies that have examined sexual harassment perpetuated by customers ^{9, 10} to women who offer them services in many occupational settings. For example, young women (hereinafter referred to as female bar workers [FBWs]) who promote the sale and consumption of beer and other alcoholic drinks in bars, beer parlours, casinos and karaokes ^{11, 12} interact on a regular basis with male customers and are vulnerable to sexual harassment. Yet, in sub-Saharan Africa (SSA), there has been limited research that has investigated sexual harassment perpetuated by male customers against this group of women.

In contrast, research in Asia has shown that these women usually experience sexual harassment from their male customers who are sometimes abusive ¹³. A study conducted among 640 FBWs in Cambodia found that over 94% experienced unwanted touching and unwelcome behaviours at least a few times per month and 24% indicated that it occurred frequently ¹⁴. The extent of male customer sexual harassment is so common that these young women experience verbal and physical abuse from their male customers ^{13, 15}. In addition, intoxicated male customers sometime resort to violence against FBWs ^{13, 16}.

There is evidence that experience of workplace sexual harassment has negative consequences on an individual’s mental health ^{17, 18}. Studies have reported that women who experience more frequent sexual harassment at work have significantly higher levels of depressive disorders than non-harassed workers ^{5, 19, 20} which may decrease work productivity and increase work stress ⁶. It has been reported that if sexual harassment is experienced in the early years of someone’s career it may lead to long-term effects on depressive symptoms in adulthood ²¹. Additionally, poor mental health as a result of sexual harassment may lead to increased absenteeism, dissatisfaction at work, lower job satisfaction as well as higher levels of job and work withdrawal ^{7, 22, 23}.

In spite the difficult working conditions of FBWs in Cameroon, no research to date has estimated the prevalence of sexual harassment perpetuated by male customers against these women at their workplace. In addition, little is known about the extent to which the experience of sexual harassment affects their mental health. The purpose of this study was to: 1) estimate the prevalence and identify the common forms of male customer sexual harassment experienced by FBWs, and 2) examine the association between forms of male customer sexual harassment and depressive symptoms among FBWs. The findings of this study will fill the gaps in the scholarly literature and generate evidence that may guide the design of workplace policies to reduce male customer sexual harassment among this group of women. This paper reports part of the findings of a larger study conducted among FBWs in Yaounde, Cameroon. The results of the other part have been published elsewhere ²⁴.

2. Methods

This study was a cross-sectional study conducted among FBWs in Yaounde, Cameroon. The detail methods of the study including sampling size calculation and sampling technique have been published elsewhere ²⁴. Briefly, we applied venue-based cluster sampling technique to select a list of entertainment venues (bars, beer parlous, karaoke and casinos) from the different administrative districts in the city of Yaounde. From this list, a random sample of venues was drawn from each district and visited by trained interviewers and FBWs at these sites were requested to participate in the study.

Data were collected after ethics approval was granted. The study team recruited interviewers who were trained on interviewing techniques, ensuring privacy and confidentiality during questionnaire administration. Interviewers were also trained on data quality assurance skills such as reviewing questionnaires for coherence and accuracy. Data were collected between May and June 2017. Interviewers had to seek permission from owners of selected entertainment venues before they could approach the FBWs to determine their eligibility for participation. Respondents were included in the study if they were: 1) at least 21 years at the time of the study; 2) had worked as a FBW for at least three months; and 3) agreed to provide written informed consent. FBWs were excluded if they did not show interest and refused to provide written informed consent to participate in the study. Prior to data collection, respondents were informed about the objectives of the study and how data collected will be used. FBWs were also informed that their participation in the study was voluntary and they could withdraw at any time. Data were collected using paper-based questionnaires in a private location.

Assessment of Depressive symptoms

The dependent variable was depressive symptoms. We assessed depressive symptoms with the five-item Mental Health Inventory (MHI-5), a subscale of the widely used SF-36 (Short Form Health Survey) designed to capture psychological distress versus well-being ²⁵. The five-item Mental Health Inventory (MHI-5) has been established as a simple and valid tool for detecting depressive symptoms in the general population ²⁶. Using the MHI-5 items, respondents were asked, “ Over the last 4 weeks, how often: (i)‘Have you felt so down in the dumps that nothing could cheer you up?’, (ii)‘Have you felt down-hearted and blue?’, (iii)‘Have you been a happy person?’, (iv)‘Have you been a very nervous person? ’and (v) ‘Have you felt calm and peaceful?’ Each item was scored on a scale of 1 to 6 as follows: all of the time (1 point), most of the time (2 points), a good bit of the time (3 points), some of the time (4 points), a little of the time (5 points), or none of the time (6 points). Since the third and fifth items are positively worded, their scores were reversed. The final MHI-5 score was calculated by summing up the item scores and transforming the score to a scale ranging from 0 to 100 with lower scores (cut-off ≤52) indicating severe depressive symptoms ²⁵.

Ascertainment of male customer sexual harassment

Sexual harassment was assessed by reading a brief definition of what constitutes sexual harassment to respondents and they were asked to disclose whether or not they had experienced such harassment from their male customers in the past 3 months. Our timeframe was defined taking into account our hypothesis that male customer sexual harassment was common in bars, beer parlours, casinos and karaokes. The definition read to respondents was: “Sexual harassment is any unwelcome sexual advance, unwelcome request for sexual favour, verbal or physical conduct or gesture of a sexual nature, or any other behaviour of a sexual nature that might reasonably be expected or be perceived to cause offence, humiliation or intimidation to the person” ²⁷. After reading the definition, respondents were asked if they had experienced any behaviour of that sort from male customers in the past 3 months. Those who indicated that they had experienced sexual harassment were provided with a list of seven behaviours likely to constitute sexual harassment and asked to disclose which of the behaviours they had experienced.

Covariates

The main covariates in the study included age as a continuous variable, marital status (never married, married, divorced/separated/widowed), level of education-in terms of highest level of education completed (primary, secondary, high school, university), monthly income and household living arrangements (living alone or with others).

In accordance with the Helsinki Declaration, the study was carried out after receiving ethical approval. The study was approved by the Cameroon National Ethical Committee for Human Subject Research (No. 2016/840/CE/CNERSH/SP). All participants were informed about the purpose of the study, voluntary participation and their discretion to withdraw at any time. All respondents provided written informed consent prior to data collection and they were assured that data collected will be kept strictly confidential.

Data analyses were performed using STATA 13.0 (Stata Corp, College Station, TX). Data were weighted to account for the complex study design and non-response. Additionally, all analyses were carried out using sample weights. We performed this using the “svyset” command taking into account survey design parameters. We adjusted for standard errors due to the clustered nature of the data by using the “svy” prefix command in STATA. Descriptive analyses such as frequencies and proportions, median and interquartile range were performed to examine respondents’ characteristics and other relevant variables. Chi-square test for categorical variables were used to assess bivariate associations between socio-demographic characteristics, forms of sexual harassment and depressive symptoms. Student’s t-test was used to determine differences between continuous independent variable (age) and the categorical variable (depressive symptoms).

Association between the forms of male customer sexual harassment and depressive symptoms were investigated using logistic regression models. Respondents with depressive symptoms were coded “1” while those without depressive symptoms were coded “0”. Before modelling, we tested for effect modification by creating interaction terms between depressive symptoms and our covariates of interest. Our aim was to determine whether the covariates modified the relationship between male customer sexual harassment and depressive symptoms. However, none of the interaction terms was significant in the model.

We then performed univariate logistic regression analysis with depressive symptoms as the dependent variable and the forms of male customer sexual harassment as independent variables. The forms of male customer sexual harassment that were significant at p<0.2 were considered candidates for multivariate logistic regression analysis. In the multivariate model, we included our co-variates of interest (age, marital status, level of educational attainment, monthly income and household living arrangements) to adjust for potential confounders. These covariates were included in the model because previous studies have found that they were related to depressive symptoms ^{28, 29, 30, 31}. Crude and Adjusted Odds Ratio (OR) and corresponding 95% confidence intervals (CI) were used to quantify the strength of the association. A two-sided p-value ≤ 0.05 was considered statistically significant.

3. Results

A total of 506 respondents were eligible for the study. Of these, 415 expressed willingness and participated in the study (response rate=82%). Nevertheless, we eliminated five questionnaires due to missing data. Consequently, 410 completed questionnaires were considered for analysis. The median age of respondents was 29 years (IQR, 25-34). Over half (58.8%) were aged 21-30 years, most (78.5%) had never married, 75.9% attained education below high school. About 67.8% had a monthly income of less than 50,000 FCFA (< 89 US $). The details of respondents’ socio-demographic characteristics have been published elsewhere ²⁴.

The median MHI-5 score (Cronbach alpha=0.63) was 60 (IQR= 44-72). An estimated 41.5% (n=170/410) of respondents met the definition of depressive symptoms in the past 4 weeks prior to the study (Table 1). The median age of those with depressive symptoms was 28 years (IQR=25-33). Higher levels of depressive symptoms were found among respondents who were never married (43.8%), those who attained education below high school level (43.1%). Respondents with a lower monthly income (<50,000 FCFA [<US$ 89]) where significantly more likely to have had depressive symptoms (44.9% vs 34.1%, p=0.024) in the past 4 weeks than those with a higher income.

Our analyses show that 98.8% (405/410) of respondents indicated that they had experienced one or more forms of sexual harassment in the past 3 months perpetuated by male customers. There was a statistically significant relationship between age (X²=6.7; df=2; p=0.019), living with someone (X²= 5.9, df=2; p=0.029) and experience of sexual harassment (data not shown). The most common forms (Figure 1) of sexual harassment experienced were: sexual advances made by male customers including requesting their telephone numbers to contact them later for a date (90.9%), sexually suggestive comments or jokes from male customers that made FBWs felt offended (76.3%), inappropriate starring or leering from male customers that made FBWs felt uncomfortable (70.7%). In addition, FBWs were subjected to other forms of harassment such as male customers asking intrusive questions about their private life and physical appearance (59.5%). Most (71.2%) FBWs indicated that it was less than one month that they last experienced sexual harassment from their male customers.

Our study found that 92.9% of respondents indicated that they received verbal insults/abuse from their male customers one month prior to the study. An estimated 71.8% indicated that verbal abuse was very frequent in their workplace. The most common psychological reactions which respondents felt after being verbally abused was afraid/fear (43.3%), offended (37.6%) and humiliated (9.0%) as shown in Figure 2.

Table 2 shows the weighted regression models for the association between forms of sexual harassment and depressive symptoms. After adjusting for potential confounders in multivariate logistic regression models, respondents who experienced inappropriate starring from their male customers that made them felt uncomfortable (AOR=3.08; 95% CI, 1.90-5.01) and those who received repeated demands for a date from male customers despite their rejection (AOR=1.61; 95% CI, 1.04-2.49) were significantly more likely to have developed depressive symptoms in the past 4 weeks.

4. Discussion

This study was designed to estimate the prevalence and identify the common forms of sexual harassment experienced by FBWs from their male customers and determine their association with depressive symptoms. The findings of this study show that male customer sexual harassment was very prevalent and some forms were independently associated with depressive symptoms. This study is unique, because it is among the first to examine this relationship among FBWs in SSA.

Overall, this study found that workplace sexual harassment against FBWs was quite common with 98.8% of respondents indicating that they had experienced one or more forms of sexual harassment in the past 3 months. The main perpetrators were male customers who visit these venues to consume beer and other alcoholic drinks. Our finding is consistent with that of a study conducted in Cambodia were over 94% (n=640) of FBWs experienced one or more forms of sexual harassment and 24% of them mentioned that it occurred frequently ¹⁴. In a similar study in Cambodia, FBWs reported that they experienced sexual harassment from male customers including unwanted sexual touching ^{32, 33}. Our finding of an association between workplace sexual harassment from male customers and depressive symptoms among this group of women is consistent with other studies although this occurred in different occupational settings ^{3, 9, 34}.

Our study found that 92.9% of FBWs experienced verbal abuse from male customers in the past one month prior to the study and 71.8% indicated that verbal abuse was very frequent. This finding is consistent with studies in Asia which reported that FBWs receive frequent verbal and physical abuse from their male customers ^{13, 15}. In this study, 43.3% of FBWs indicated that they were afraid the last time they received verbal abuse from their male customers (Figure 2). This finding suggests that workplace verbal abuse may be associated with negative psychological reactions ^{7, 8} which might affect the mental health of respondents. Among women in other occupational settings, such experiences may also negatively affect job satisfaction, performance and increases work withdrawal ³⁵. However, in the setting where this study was conducted, despite these abuses, some of these FBWs may develop coping mechanisms rather than quitting their jobs because of the limited employment opportunities in the city.

This study found that 41.5% of FBWs had depressive symptoms within the past 4 weeks prior to the study and some forms of sexual harassment were positively associated with depressive symptoms. After adjustment for potential confounders, respondents who experienced inappropriate starring from their male customers that made them felt uncomfortable were three times more likely to have experienced depressive symptoms in the past 4 weeks. Furthermore, those who received repeated demands for a date from their male customers despite their rejection were more likely to have experienced depressive symptoms. Even after adjusting for potential confounders, the association between the two main forms of sexual harassment and depressive symptoms remain significant suggesting that the relationship is independent of the confounding variables that were controlled. These forms of sexual harassment may affect the emotions and mood of respondents which may affect their mental health. Studies have consistently demonstrated that women who experience workplace sexual harassment suffer significant psychological, health and job-related consequences ^{5, 7, 8}.

Our study has several strengths. First, we recruited a representative sample of FBWs in the city and because data were weighted prior to analysis, the findings could be generalised among FBWs in Yaounde. This study has shed light on the common forms of sexual harassment perpetuated by male customers against FBWs and how this affect their mental health. Secondly, we explained to respondents the definition of what constitutes sexual harassment to enable them understand its meaning before asking them whether or not they had experienced such behaviours from their male customers. The findings of this study should be interpreted bearing in mind a few limitations. First, the cross-sectional design means that causality cannot be established. Second, the study relied on self-reported experiences of sexual harassment and abuse which may be subject to response bias as it is likely that respondents may have over-reported or under-reported their experience of sexual harassment from male customers. In spite of these limitations, the present study has enriched our understanding of the forms of male customer sexual harassment experienced by FBWs and its association with depressive symptoms. These findings highlight the need for targeted interventions and the establishment of psychosocial support services to address depressive symptoms among FBWs in the city. The findings are also important as it may guide the design of workplace policies to reduce sexual harassment perpetuated by male customers and protect the health and psychosocial well-being of these young women. Future studies are required to further understand this relationship. Qualitative studies designed to understand the coping mechanisms used by these FBWs amidst the pervasive nature of sexual harassment and verbal abuse from male customers in their workplace would also contribute to increase the knowledge base. Finally, similar studies among FBWs are required in other countries in SSA which will contribute to increase the academic scholarship on sexual harassment among this group of women.

5. Conclusions

This study found that FBWs experience high rates of workplace sexual harassment from their male customers and this was independently associated with depressive symptoms. These findings underscore the need for owners of entertainment venues to collaborate with local authorities and identify ways that could reduce sexual harassment against these women. It is important that awareness raising and sensitization campaigns should be carried out to educate male customers about sexual harassment and how this affects the mental health of FBWs. Finally, there is a need for the establishment of services for the diagnosis and treatment of depression and other mental health disorders among FBWs and other at-risk populations in the community.

Acknowledgements

We gratefully acknowledge Mr Nchoutpouen Limi Cyrille and Mrs Vera Ndobe for their contribution and support during data collection and data entry. Special thanks also goes to all female bar workers who dedicated their time to participate in this study.

Source of Support or Funding

No funding was received for this study.

Statement of Competing Interests

The authors declare that they have no potential conflicts of interest.

List of Abbreviations

AOR: Adjusted Odds Ratio;

HIV: Human Immuno-Deficiency Virus

CI: Confidence Interval;

FBWs: Female Bar Workers;

IQR: Inter Quartile Range;

MHI: Mental Health Inventory;

OR: Odds Ratio

References