AIDS and Behavior

, Volume 21, Issue 12, pp 3567–3577 | Cite as

Can Burt’s Theory of Structural Holes be Applied to Study Social Support Among Mid-Age Female Sex Workers? A Multi-Site Egocentric Network Study in China

  • Hongjie Liu
Original Paper


The epidemic of HIV/AIDS continues to spread among older adults and mid-age female sex workers (FSWs) over 35 years old. We used egocentric network data collected from three study sites in China to examine the applicability of Burt’s Theory of Social Holes to study social support among mid-age FSWs. Using respondent-driven sampling, 1245 eligible mid-age FSWs were interviewed. Network structural holes were measured by network constraint and effective size. Three types of social networks were identified: family networks, workplace networks, and non-FSW networks. A larger effective size was significantly associated with a higher level of social support [regression coefficient (β) 5.43–10.59] across the three study samples. In contrast, a greater constraint was significantly associated with a lower level of social support (β −9.33 to −66.76). This study documents the applicability of the Theory of Structural Holes in studying network support among marginalized populations, such as FSWs.


Theory of structural holes Egocentric network Social support Mid-age female sex workers China 



I am grateful to the staff from Shandong University School of Public Health, Nanning Center for Disease Control and Prevention, Hefei Center for Diseases Control and Prevention, and Qingdao Center for Disease Control and Prevention for their participation in the study, and to all the participants who willingly gave their time to provide the study data.


This work was funded by National institutes of Health (R01HD068305).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Joint United Nations Programme on HIV/AIDS. Prevention gap report. Geneva: UNAIDS; 2016.Google Scholar
  2. 2.
    Nash P, Willis P, Tales A, Cryer T. Sexual health and sexual activity in later life. Rev Clin Gerontol. 2015;25(1):22–30.CrossRefGoogle Scholar
  3. 3.
    Minichiello V, Rahman S, Hawkes G, Pitts M. STI epidemiology in the global older population: emerging challenges. Perspect Public Health. 2012;132(4):178–81.CrossRefPubMedGoogle Scholar
  4. 4.
    Liu H, Lin X, Xu Y, Chen S, Shi J, Morisky D. Emerging HIV epidemic among older adults in Nanning, China. AIDS Patient Care STDS. 2012;26(10):565–7.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Pearline RV, Tucker JD, Yuan LF, et al. Sexually transmitted infections among individuals over fifty years of age in China. AIDS Patient Care STDS. 2010;24(6):345–7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hao C, Liu H, Sherman S, et al. Typology of older female sex workers and sexual risks for HIV infection in China: a qualitative study. Cult Health Sex. 2014;16(1):47–60.CrossRefPubMedGoogle Scholar
  7. 7.
    Han L, Zhou C, Li Z, et al. Differences in risk behaviours and HIV/STI prevalence between low-fee and medium-fee female sex workers in three provinces in China. Sex Transm Infect. 2016;92(4):309–15.CrossRefPubMedGoogle Scholar
  8. 8.
    Wang L, Tang W, Wang L, et al. The HIV, syphilis, and HCV epidemics among female sex workers in china: results from a serial cross-sectional study between 2008 and 2012. Clin Infect Dis. 2014;59(1):e1–9.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Li D, Wang L, Lin W, et al. HIV and syphilis infections among street-based female sex workers in China, 2010-2012. Chin Med J (Engl). 2014;127(4):707–11.PubMedGoogle Scholar
  10. 10.
    Chen Y, Abraham Bussell S, Shen Z, et al. Declining inconsistent condom use but increasing HIV and syphilis prevalence among older male clients of female sex workers: analysis from sentinel surveillance sites (2010–2015), Guangxi, China. Medicine. 2016;95(22):e3726.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Liu H, Dumenci L, Morisky DE, Xu Y, Li X, Jiang B. Syphilis among middle-aged female sex workers in China: a three-site cross-sectional study. BMJ Open. 2016;6(5):e010420.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Gil VE, Wang MS, Anderson AF, Lin GM, Wu ZO. Prostitutes, prostitution and STD/HIV transmission in mainland China. Soc Sci Med. 1996;42(1):141–52.CrossRefPubMedGoogle Scholar
  13. 13.
    Pirkle C, Soundardjee R, Stella A. Female sex workers in China: vectors of disease? Sex Transm Dis. 2007;34(9):695–703.CrossRefPubMedGoogle Scholar
  14. 14.
    Huang Y, Henderson GE, Pan S, Cohen MS. HIV/AIDS risk among brothel-based female sex workers in China: assessing the terms, content, and knowledge of sex work. Sex Transm Dis. 2004;31(11):695–700.CrossRefPubMedGoogle Scholar
  15. 15.
    Ruan Y, Cao X, Qian HZ, et al. Syphilis among female sex workers in southwestern China: potential for HIV transmission. Sex Transm Dis. 2006;33(12):719–23.CrossRefPubMedGoogle Scholar
  16. 16.
    Wang H, Chen RY, Ding G, et al. Prevalence and predictors of HIV infection among female sex workers in Kaiyuan City, Yunnan Province. China. Int J Infect Dis. 2009;13(2):162–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Valente TW. Social networks and health: models, methods, and applications. 1st ed. NY: Oxford University Press; 2010.CrossRefGoogle Scholar
  18. 18.
    Morris M. Overview of network survey designs. In: Morris M, editor. Network epidemiology. USA: Oxford University Press; 2004.CrossRefGoogle Scholar
  19. 19.
    Hall A, Wellman B. Social networks and social support. In: Cohen S, Symes SL, editors. Social support and health. Orlando: Academic Press, INC.; 1985. p. 23–41.Google Scholar
  20. 20.
    Knowlton A, Hua W, Latkin C. Social support among HIV positive injection drug users: implications to integrated intervention for HIV positives. AIDS Behav. 2004;8(4):357–63.CrossRefPubMedGoogle Scholar
  21. 21.
    House J, Kahn R. Measures and concepts of social support. In: Cohen S, Leonard S, editors. Social support and health. San Diego: Academic Press; 1985. p. 83–108.Google Scholar
  22. 22.
    Miller M, Neaigus A. Networks, resources and risk among women who use drugs. Soc Sci Med. 2001;52(6):967–78.CrossRefPubMedGoogle Scholar
  23. 23.
    Cohen S, Mermelstein R, Kamarck T, Hoberman HM. Measuring the functional components of social support. In: Sarason IG, Sarason BR, editors. Social report: theory, research and application. Boston: Martinus Nijhoff; 1985. p. 73–94.CrossRefGoogle Scholar
  24. 24.
    House JS. Social support and social structure. Sociol Forum. 1987;2(1):135–46.CrossRefGoogle Scholar
  25. 25.
    Latkin CA, Knowlton AR. Micro-social structural approaches to HIV prevention: a social ecological perspective. AIDS Care. 2005;17(Suppl 1):S102–13.CrossRefPubMedGoogle Scholar
  26. 26.
    Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98(2):310–57.CrossRefPubMedGoogle Scholar
  27. 27.
    Kahn RL. Aging and social support. In: Riley MW, editor. Aging from birth to death: Interdisciplinary perspectives. Boulder: Westview Press; 1979. p. 77–91.Google Scholar
  28. 28.
    Lakon CM, Godette DC, Hipp JR. Network-based approaches for measuring social capital. In: Kawachi I, Subramanian SV, Kim D, editors. Social capital & health. New York: Springer; 2007. p. 63–81.Google Scholar
  29. 29.
    Johnson BT, Redding CA, DiClemente RJ, et al. A network-individual-resource model for HIV prevention. AIDS Behav. 2010;14(Suppl 2):204–21.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Latkin C, Weeks MR, Glasman L, Galletly C, Albarracin D. A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS Behav. 2010;14(Suppl 2):222–38.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Liu H, Feng T, Liu H, et al. Egocentric networks of Chinese men who have sex with men: network components, condom use norms and safer sex. AIDS Patient Care STDS. 2009;23:885–93.CrossRefPubMedGoogle Scholar
  32. 32.
    Triandis C. Individualism and collectivism. In: Ricky D, editor. Handbook of culture and psychology. Cary: Oxford University; 2001. p. 35–50.Google Scholar
  33. 33.
    Hui CH, Triandis HC. Individualism-collectivism: a study of cross-cultural researchers. J Cross Cul Psychol. 1986;17(2):225–48.CrossRefGoogle Scholar
  34. 34.
    Murray-Johnson L, Witte K, Liu W-Y, Hubbell AP, Sampson J, Morrison K. Addressing cultural orientation in fear appeals: promoting AIDS-protective behaviors among Mexican immigrant and African American adolescents and American and Taiwanese college students. J Health Commun. 2001;6(4):335–58.CrossRefPubMedGoogle Scholar
  35. 35.
    Triandis HC. Self and social behavior in differing cultural contexts. Psychol Rev. 1989;96:269–89.CrossRefGoogle Scholar
  36. 36.
    Liu H. Egocentric network and condom use among mid-age female sex workers in china: a multilevel modeling analysis. AIDS Patient Care STDS. 2016;30(4):155–65.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Hao C, Guida J, Morisky D, Liu H. Family network, workplace network, and their influence on condom use: a qualitative study among older female sex workers in China. The J Sex Res. 2015;52(8):924–35.CrossRefPubMedGoogle Scholar
  38. 38.
    Crossley N, Elisa B, Edwards G, Everett MG, Koskinen J, Tranmer M. Social network analysis for ego-nets. London: SAGE; 2015.Google Scholar
  39. 39.
    Coleman J. Foundations of social theory. Cambridge: Belnap Press; 1994.Google Scholar
  40. 40.
    Burt RS. Structural holes: the social structure of competition. Cambridge: First Harvard University Press: Harvard University; 1995.Google Scholar
  41. 41.
    Burt RS, Kilduff M, Tasselli S. Social network analysis: foundations and frontiers on advantage. Annu Rev Psychol. 2013;64(1):527–47.CrossRefPubMedGoogle Scholar
  42. 42.
    Granovetter MS. The strength of weak ties. Am J Soc. 1973;78(6):1360–80.CrossRefGoogle Scholar
  43. 43.
    Burt RS. Reinforced structural holes. Soc Netw. 2015;43:149–61.CrossRefGoogle Scholar
  44. 44.
    Shah NS, Iveniuk J, Muth SQ, et al. Structural bridging network position is associated with HIV status in a younger Black men who have sex with men epidemic. AIDS Behav. 2014;18(2):335–45.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Liu H, Morisky DE, Lin X, Ma E, Jiang B, Yin Y. Bias in self-reported condom use: association between over-Reported condom use and syphilis in a three-site study in China. AIDS Behav. 2016;20(6):1343–52.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Ministry of Health of the People’s Republic of China. 2012 China AIDS response progress report Beijing: China Ministry of Health; March 31, 2012.[1].pdf. Accessed 8 Jun 2017.
  47. 47.
    Lianne AU, Robert MM, Nina CS, Donald EM. Age differences among female sex workers in the philippines: sexual risk negotiations and perceived manager advice. AIDS Res Treat. 2012;2012:812635.Google Scholar
  48. 48.
    Heckathorn DD. Extensions of respondent-driven sampling: analyzing continuous variables and controlling for differential recruitment. Sociol Methodol. 2007;37(1):151–208.CrossRefGoogle Scholar
  49. 49.
    Gile KJ, Johnston LG, Salganik MJ. Diagnostics for respondent-driven sampling. J R Stat Soc. 2015;178(1):241–69.CrossRefGoogle Scholar
  50. 50.
    Koram N, Liu H, Li J, Luo J, Nield J. Role of social network dimensions in the transition to injection drug use: actions speak louder than words. AIDS Behav. 2011;15(7):1579–88.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Norbeck JS. The norbeck social support questionnaire. Birth Defects Orig Aartic Ser. 1984;20(5):45–57.Google Scholar
  52. 52.
    Borgatti SP, Everett MG, Freeman LC. Ucinet for windows: software for social network analysis. Harvard: Analytic Technologies; 2002.Google Scholar
  53. 53.
    Choudhury SM, Toller Erausquin J, Park K, Anglade D. Social support and sexual risk among establishment-based female sex workers in Tijuana. Qual Health Res. 2015;25(8):1056–68.CrossRefPubMedGoogle Scholar
  54. 54.
    Chen R, Tao F, Ma Y, Zhong L, Qin X, Hu Z. Associations between social support and condom use among commercial sex workers in China: a cross-sectional study. PLoS ONE. 2014;9(12):e113794.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Hiller SP, Syvertsen JL, Lozada R, Ojeda VD. Social support and recovery among Mexican female sex workers who inject drugs. J Subst Abuse Treat. 2013;45:44–54.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Rudolph A, Linton S, Dyer T, Latkin C. Individual, network, and neighborhood correlates of exchange sex Among female non-injection drug users in Baltimore, MD (2005–2007). AIDS Behav. 2013;17(2):598–611.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Yang H, Li X, Stanton B, Fang X, et al. Condom use among female sex workers in China: role of gatekeepers. Sex Transm Dis. 2005;32(9):572.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Lazer D, Friedman A. The network structure of exploration and exploitation. Adm Sci O. 2007;2007(52):667–94.CrossRefGoogle Scholar
  59. 59.
    Friedman MR, Coulter RW, Silvestre AJ, et al. Someone to count on: social support as an effect modifier of viral load suppression in a prospective cohort study. AIDS Care. 2017;29(4):469–80.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of Epidemiology and Biostatistics, School of Public HealthUniversity of Maryland, College ParkCollege ParkUSA

Personalised recommendations