Client-Seeking Environments, Safety Management, and Survival Strategies Among African male and gender-diverse refugee/migrant workers in Northern Italy: A Theory of Planned Behavior Mixed-Methods Study. BSGH026

Client-Seeking Environments, Safety Management, and Survival Strategies Among African male and gender-diverse refugee/migrant workers in Northern Italy: A Theory of Planned Behavior Mixed-Methods Study. BSGH026 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Client-Seeking Environments, Safety Management, and Survival Strategies Among African male and gender-diverse refugee/migrant workers in Northern Italy: A Theory of Planned Behavior Mixed-Methods Study. BSGH026 Osman Wumpini Shamrock, Gamji Rabiu Abu-Ba’are, Samira Shirzaei Nichols, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9202242/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background African male and gender-diverse refugee/migrant workers in Europe face intersecting structural vulnerabilities that shape HIV/STI risk. Client-seeking environments may influence sexual health behaviors, yet limited evidence examines how venue-based strategies affect condom use, STI disclosure, and risk negotiation. Methods We conducted a sequential exploratory mixed-methods study among African male and gender-diverse refugee/migrant workers in Northern Italy. Qualitative data from 20 in-depth interviews and 2 focus group discussions informed a structured survey administered to 150 participants. Guided by the Theory of Planned Behavior, we examined associations between client-seeking venues and sexual health outcomes, including condom use, STI disclosure, awareness of clients’ STI status, and engagement in unprotected sex under financial pressure. Fisher’s Exact Test and two-proportion z-tests were used (p < 0.05). Results Referral-based networks were the most common client-seeking strategy (62.7%), followed by bars/clubs (14.0%), street-based work (13.3%), online platforms (6.7%), and brothels (3.3%). Client-seeking venue was significantly associated with awareness of clients’ STI status (p = 0.003), condom use (p = 0.009), STI disclosure (p = 0.005), and acceptance of unprotected sex (p = 0.011). Online-based sex work was associated with the lowest condom use and STI disclosure, while brothel-based work showed higher reported condom use and STI awareness. Qualitative findings indicated that differences in peer support, negotiation dynamics, and perceived control across venues shaped these outcomes. Conclusions Client-seeking environments are critical determinants of HIV/STI risk among AMGRM. Venue-specific interventions that strengthen peer networks, improve condom negotiation capacity, and integrate digital health strategies are needed to reduce risk and enhance engagement in HIV prevention and care. Health Policy migrant sex workers refugee populations condom use STI disclosure digital sex work peer networks HIV risk Theory of Planned Behavior Italy Full Text Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9202242","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610813509,"identity":"7700cb4d-0359-4003-b3c5-d48c71f0d737","order_by":0,"name":"Osman Wumpini Shamrock","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYFACHgjJL8HYwABEUMBGWIuM5AyoFh5itdgY3ACSRGnh5z978NPNPTY8xreb2x5+3WEXbc/ee4DhQ9lhnFokZ+QlS+c8S+Mxu3Ow3Vj2THJuD8+5BMYZ53BrMbjBYyCdc+Awj9mNxDZpyTbm3B6JHANm3jY8Ws6fMf4N0mI8A6ylHqLlLz4tB3LMwLYYSCS2SX5sOwzRwohHi+SMHDPrnANpPBJ3DrZJM7Ydz+05c8bgYM+5dJxa+PnPGN/OOWBjzz+7/Znkz7bq3Pb2HsMHP8qscWpBAcw8UMYB4tQDAeMPopWOglEwCkbBSAIAX8FXlJtEBfEAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3127-9596","institution":"Behavioral, Sexual, and Global Health Lab, School of Nursing, University of Rochester Medical Center, Rochester, New York, United States","correspondingAuthor":true,"prefix":"","firstName":"Osman","middleName":"Wumpini","lastName":"Shamrock","suffix":""},{"id":610813510,"identity":"a6df63b9-dbf8-4114-8fdd-6b3e80ce96bb","order_by":1,"name":"Gamji Rabiu Abu-Ba’are","email":"","orcid":"https://orcid.org/0000-0002-1718-0381","institution":"Behavioral, Sexual, and Global Health Lab, School of Nursing, University of Rochester Medical Center, Rochester, New York, United States","correspondingAuthor":false,"prefix":"","firstName":"Gamji","middleName":"Rabiu","lastName":"Abu-Ba’are","suffix":""},{"id":610813511,"identity":"a7c00606-11e5-46a4-87b8-ead10cddacca","order_by":2,"name":"Samira Shirzaei Nichols","email":"","orcid":"https://orcid.org/0000-0002-5722-7017","institution":"Department of Computer Information Systems \u0026 Analytics, College of Business, University of Central Arkansas, Arkansas, United States","correspondingAuthor":false,"prefix":"","firstName":"Samira","middleName":"Shirzaei","lastName":"Nichols","suffix":""},{"id":610813512,"identity":"e231b5ee-75f2-4fdf-984c-c528b9d1acd4","order_by":3,"name":"Marco Barracchia","email":"","orcid":"","institution":"Department of International Health, Care and Public Health Research Institute (CAPHRI) Maastricht University, Maastricht, The Netherlands","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Barracchia","suffix":""},{"id":610813513,"identity":"3b4a13f5-eaab-4e58-9dc4-73b61c05d694","order_by":4,"name":"George Rudolph Kofi Agbemedu","email":"","orcid":"https://orcid.org/0000-0003-1759-715X","institution":"Behavioral, Sexual, and Global Health Lab, School of Nursing, University of Rochester Medical Center, Rochester, New York, United States","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"Rudolph Kofi","lastName":"Agbemedu","suffix":""},{"id":610813514,"identity":"a3c2cd36-159b-42d9-8052-e317716ada13","order_by":5,"name":"Charles Gagbe Nukunu","email":"","orcid":"https://orcid.org/0009-0004-8329-4549","institution":"University of Miami, School of Nursing and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"Gagbe","lastName":"Nukunu","suffix":""},{"id":610813515,"identity":"2ca44828-fbf3-42c6-ada8-44359fe18a40","order_by":6,"name":"Adams Al-Mardhiyyah","email":"","orcid":"","institution":"Department of Computer Information Systems \u0026 Analytics, College of Business, University of Central Arkansas, Arkansas, United States","correspondingAuthor":false,"prefix":"","firstName":"Adams","middleName":"","lastName":"Al-Mardhiyyah","suffix":""}],"badges":[],"createdAt":"2026-03-23 15:09:31","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9202242/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9202242/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105564564,"identity":"3f215527-1e14-4740-9a85-6fd95264821b","added_by":"auto","created_at":"2026-03-27 12:50:03","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":580523,"visible":true,"origin":"","legend":"","description":"","filename":"newClient1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9202242/v1_covered_48f07fe6-8953-478a-b10c-95331fad2198.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eClient-Seeking Environments, Safety Management, and Survival Strategies Among African male and gender-diverse refugee/migrant workers in Northern Italy: A Theory of Planned Behavior Mixed-Methods Study. BSGH026\u003c/strong\u003e\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[{"identity":"a88451c1-fda5-46e2-8b09-ad1bc330d29a","identifier":"10.13039/100000025","name":"National Institute of Mental Health","awardNumber":"P30MH062294","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Rochester","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"migrant sex workers, refugee populations, condom use, STI disclosure, digital sex work, peer networks, HIV risk, Theory of Planned Behavior, Italy","lastPublishedDoi":"10.21203/rs.3.rs-9202242/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9202242/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAfrican male and gender-diverse refugee/migrant workers in Europe face intersecting structural vulnerabilities that shape HIV/STI risk. Client-seeking environments may influence sexual health behaviors, yet limited evidence examines how venue-based strategies affect condom use, STI disclosure, and risk negotiation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a sequential exploratory mixed-methods study among African male and gender-diverse refugee/migrant workers in Northern Italy. Qualitative data from 20 in-depth interviews and 2 focus group discussions informed a structured survey administered to 150 participants. Guided by the Theory of Planned Behavior, we examined associations between client-seeking venues and sexual health outcomes, including condom use, STI disclosure, awareness of clients\u0026rsquo; STI status, and engagement in unprotected sex under financial pressure. Fisher\u0026rsquo;s Exact Test and two-proportion z-tests were used (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eReferral-based networks were the most common client-seeking strategy (62.7%), followed by bars/clubs (14.0%), street-based work (13.3%), online platforms (6.7%), and brothels (3.3%). Client-seeking venue was significantly associated with awareness of clients\u0026rsquo; STI status (p\u0026thinsp;=\u0026thinsp;0.003), condom use (p\u0026thinsp;=\u0026thinsp;0.009), STI disclosure (p\u0026thinsp;=\u0026thinsp;0.005), and acceptance of unprotected sex (p\u0026thinsp;=\u0026thinsp;0.011). Online-based sex work was associated with the lowest condom use and STI disclosure, while brothel-based work showed higher reported condom use and STI awareness. Qualitative findings indicated that differences in peer support, negotiation dynamics, and perceived control across venues shaped these outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eClient-seeking environments are critical determinants of HIV/STI risk among AMGRM. Venue-specific interventions that strengthen peer networks, improve condom negotiation capacity, and integrate digital health strategies are needed to reduce risk and enhance engagement in HIV prevention and care.\u003c/p\u003e","manuscriptTitle":"Client-Seeking Environments, Safety Management, and Survival Strategies Among African male and gender-diverse refugee/migrant workers in Northern Italy: A Theory of Planned Behavior Mixed-Methods Study. BSGH026","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 09:22:59","doi":"10.21203/rs.3.rs-9202242/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d573235-4bc4-4eb9-8cdc-b46b8cdda1a7","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64990959,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-03-24T09:22:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 09:22:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9202242","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9202242","identity":"rs-9202242","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}