The Effect of Emotional Intelligence and Employment on the Psychological Well-Being of HIV Key Population Workers

By Usman Ali¹, Batool Fatima², Sidra Azmat³, Muhammad Shaheryar Khan¹, Ramisha Chaudhary⁴, Ali Mirzazadeh⁵

Affiliations

1. Department of Psychiatry and Behavioural Sciences, King Edward Medical University, Lahore, Pakistan
2. Department of Community Health Sciences, The Aga Khan University Hospital, Karachi, Pakistan
3. United Nations Development Programme, Pakistan
4. Department of Psychiatry and Behavioural Sciences, Nishtar Medical University, Multan, Pakistan
5. Department of Epidemiology and Biostatistics, University of California, San Francisco, United States of America

doi: 10.29271/jcpsp.2025.10.1294

ABSTRACT
Objective: To assess the duration of employment and examine the impact of emotional intelligence on the psychological well-being of men who have sex with men (MSM), trans women (TW), and female sex workers (FSW) working in HIV community-based organisations (CBOs) in Pakistan.
Study Design: Explanatory sequential mixed-methods study.
Place and Duration of the Study: CBOs in 16 districts and 50 sites across Pakistan, from November 2023 to April 2024.
Methodology: Individuals over 18 years of age, self-identifying as MSM, TW, or FSW, and working at a CBO were enrolled. Psychological well-being was measured using the Ryff’s psychological well-being scale, and emotional intelligence was measured using the Wong and Law Emotional Intelligence scale (WLEIS). The multiple linear regression was used to identify predictors of psychological well-being. Ten in-depth qualitative interviews were also conducted among CBO workers.
Results: A total of 188 CBO workers were included in the quantitative survey; of these, 128 (68.1%) were MSM, 18 (9.6%) were FSW, and 42 (22.3%) were TW. The multiple regression analysis showed that residence away from family (β = 2.85; p = 0.038), history of suicidal ideation (β = -3.74; p = 0.022), and emotional intelligence (β = 3.25; p <0.001) were significant predictors of psychological well-being. The qualitative analysis showed a positive effect of CBO employment, contributing to professional growth and empowerment and acceptance of gender and sexuality.
Conclusion: Living away from family and having higher emotional intelligence were positive predictors of psychological well-being. A history of suicidal ideation was associated with poor psychological well-being. There is qualitative evidence that suggests that CBO employment improves psychological well-being.

Key Words: Men who have sex with men, Trans women, Female sex workers, Psychological well-being, HIV, Community-based organisations.

INTRODUCTION

Men who have sex with men (MSM), trans women (TW), and female sex workers (FSW) are at increased risk of HIV due to an increased number of sexual partners, unsafe sex, and other risky behaviours.¹ These communities are stigmatised globally, regardless of their HIV status, due to social and cultural factors.¹

According to the United Nations Joint Programme on HIV/ AIDS (UNAIDS), 63 countries criminalise same sex behaviour between men, thirteen countries criminalise gender expression of transgender people, and 169 countries criminalise some aspect of sex work.¹ Global report on HIV stigma and discrimination states that 40.5% of MSM, 49.4% of TG, and 25.7% of SW face discrimination.² Research shows that belonging to an HIV key population, i.e., MSM, TG, or FSW, and experiencing stigma is associated with poor psychological well-being.³ Evidence from meta-analysis shows that the prevalence of depression is 35% among MSM and 44% among FSWs.^4,5 Furthermore, transgender people have eight times higher odds of being diagnosed with a mental health disorder compared to cisgender people.⁶

MSM, transgender, and FSW face a high level of stigma in Pakistan. According to a nationwide survey, 31.3% of MSM, 52% of transgender people, and 35.6% of FSW are reported being discriminated against,⁷ while 6.3% of MSM, 16.6% of transgender individuals, and 6.6% of FSW are reported being denied or treated unfairly in the healthcare system.⁷ A previous study among people living with HIV in Pakistan reported a significant relationship between depressive symptoms and engagement in sex work.⁸

To galvanise the HIV response in Pakistan, community-based organisations (CBOs) have been established to deliver services within the HIV prevention programmes. These organisations provide employment to the members of MSM, TW, and FSW communities in almost all positions, including management and leadership.⁹ The underlying philosophy is to empower these communities and to reduce barriers to healthcare access by offering prevention services through their community members. Furthermore, CBOs create a validating environment, contrary to the mainstream employment sector for these communities. Workplace support and affirming behaviours are associated with enhanced life satisfaction among gay men and trans women.³ However, to date, no study has assessed whether employment in CBOs leads to improved psychological well-being in Pakistan.

While belonging to MSM, TW, and FSW groups is associated with poor mental health, protective factors against psychiatric comorbidities have not been previously researched in Pakistan. The only study assessing the prevalence of depressive symptoms among CBO workers was conducted by Ali et al.⁹ One such protective factor is emotional intelligence, defined as the capacity to correctly identify and manage one’s own emotions, recognise emotions of others, and demonstrate empathy.¹⁰ Higher emotional intelligence buffers stress and can lead to post- traumatic growth.¹¹ Dafeeh et al. explored predictors of emotional intelligence among HIV health professionals and found that higher emotional intelligence was associated with greater work experience and a positive attitude towards HIV communities.¹² The study, however, did not explore employment in community-based organisations or whether the health workers belonged to HIV key populations. Higher emotional intelligence improves employee well-being and work performance.¹³ However, the effect of employment in CBOs of HIV key population health workers on emotional intelligence is not explored.

The objective of this study was to assess the duration of employment in CBO and examine the impact of emotional intelligence on the psychological well-being of MSM, TW, and FSW  working  in  HIV  CBOs  in  Pakistan.

METHODOLOGY

The study protocol was reviewed and approved by the Research Ethics Committee of the King Edward Medical University, Lahore, Pakistan (REC No. 09/IM/2023; Dated: 21-09-2023). An explanatory sequential mixed-methods study was conducted from November 2023 to April 2024. The study was conducted across CBOs throughout Pakistan, encompassing fifty-two sites in 18 districts (Figure 1). Individuals over 18 years of age, self-identifying as MSM, TW, or FSW, and working at an HIV- related CBO were recruited. People under professional mental health care in the last five years were excluded from the study. Since the study population, that is MSM, TW, and FSWs employed in CBOs, was around 320 individuals, the study included all individuals who met the inclusion and exclusion criteria. Informed written consent was taken from participants. The research tool included a sociodemographic questionnaire, the Wong and Law emotional intelligence scale (WLEIS), and Ryff’s psychological well-being scale. The WLEIS is a 16-item scale rated on 7-items Likert scale, with scores reflecting levels of emotional intelligence.¹⁴ The psychological well-being was measured using Ryff’s psychological well-being scale.¹⁵ Ryff’s scale is also based on a Likert-type scoring scale. On both of these scales, a higher score represents better psychological well-being and emotional intelligence. Urdu versions were used.^14,15 An inception webinar was conducted before data collection by the principal investigator and the managers of CBOs, explaining the significance of the study and the support needed. Each CBO had nominated a site focal person who was trained in data collection. The data were collected in paper-based format, entered into Microsoft Excel, and subsequently imported into the Statistical Package for Social Sciences (SPSS) Version 26.0. Descriptive statistics were computed for sociodemographic variables. Cronbach’s alpha was computed for Ryff’s psychological well-being scale and WLEIS. The normality of Ryff’s psychological well-being scores was checked using the Kolmogorov-Smirnov test. As the data were not normally distributed, Spearman's and point biserial correlation coefficients were computed to find factors correlated with Ryff’s psychological well-being score. Factors associated with correlation coefficients ≥+0.1 or ≤-0.1 were included in the multiple linear regression model, using the enter method, as used elsewhere in previous literature.⁸ Assumptions for linear regression were tested.⁸

In-depth interviews of ten CBO workers were conducted using a semi-structured interview guide. Participants were recruited through maximum diversity sampling. Verbal consent was taken for interviews. Interviews were conducted in Urdu, which was later translated into English. Thematic analysis was conducted manually. Coding was led by a lead researcher, followed by a discussion with another researcher. The lead researcher had previously worked at a CBO and had been engaged in the HIV response, thereby providing a strong understanding of community dynamics and allowing for a nuanced approach to data analysis. Coding disagreements were settled through discussion and consensus between the two researchers and further reviewed by numbers of the research team.

RESULTS

A total of 188 CBO workers were included in the quantitative survey; of these, 128 (68.1%) were MSM, 18 (9.6%) were FSW, and 42 (22.3%) were TW. The sociodemographic characteristics of study participants are summarised in Table I.

 Table I: Sociodemographic characteristics of MSM, TW, and FSW working in HIV CBOs in Pakistan, 2024 (n = 188).

Characteristics	Total (n = 188)
Age in years (mean ±SD)	31.05 ± 7.3
Subgroups
MSM	128 (68.1%)
FSW	18 (9.6%)
TW	42 (22.3%)
Residence
Away from family	56 (29.8%)
With family	132 (70.2%)
Currently partnered
Yes	75 (39.9%)
No	113 (60.1%)
CBO employment in years (median, interquartile range)	0.72 (0.35-2.5)
Are you currently stressed?
Yes	69 (36.7%)
No	119 (63.3%)
History of self-harm
Yes	26 (13.8%)
No	162 (86.2%)
History of suicidal ideation
Yes	51 (27.1%)
No	137 (72.9%)

Table II: Results of multiple linear regression of psychological well-being score of MSM, TW, and FSW employed in HIV CBOs in Pakistan, 2024 (n = 188).

Models	Unstandardised coefficient		t	Significance*	95% CI
	B	Standard errors			Lower limit	Upper limit
Constant	66.043	5.526	11.952	0.001	55.140	76.946
Residence away from family	2.859	1.371	2.086	0.038	0.154	5.564
History of self-harm	-2.964	1.939	-1.529	0.128	-6.789	0.862
History of suicidal ideation	-3.746	1.615	-2.319	0.022	-6.933	-0.559
Being stressed currently	-1.967	1.438	-1.368	0.173	-4.804	0.871
Emotional intelligence score	3.254	.899	3.619	<0.001	1.480	5.028
FSW	-3.530	2.143	-1.647	0.101	-7.759	0.699
*p-values were determined by multiple linear regression estimated via the ordinary Least squares method.

Table III: Sociodemographic characteristics of MSM, TW, and FSW working in HIV CBOs included in the in-depth interviews, Pakistan, 2024 (n = 10).

Participant IDs	Age in years	Subgroups	Education	Job ranks	Experience in CBOs	Experience other than CBOs
P1	38	TW	12th grade	Service provider	12 years on and off	Dancing, sex work
P2	42	MSM	Masters	Management cadre	12 years persistently	Worked in the corporate and private sector
P3	35	MSM	Bachelors	Service provider	6 years persistently	Before CBO, employment was employed in an HIV service NGO for six years
P4	38	MSM	Masters	Management cadre	12 years	Worked in the corporate and private sectors
P5	44	MSM	Masters	Management cadre	12 years on and off	Worked in the corporate and private sectors
P6	29	MSM	Masters	Management cadre	Less than 1 year	Worked in the corporate and private sectors
P7	29	TW	Bachelors	Service provider	Less than 1 year	Worked outside Pakistan
P8	38	MSM	Masters	Management cadre	Less than 1 year	Worked in the private sector
P9	32	FSW	10th grade	Service provider	6 years	Never worked
P10	43	FSW	10th grade	Service provider	Less than 1 year	Private sector

Cronbach’s alpha for Ryff’s psychological well-being and the WLEIS was 0.584 and 0.767, respectively. Spearman’s correlation coefficient between Ryff’s psychological well-being score and age was 0.03 (p = 0.98), and with years of employment was -0.095 (p = 0.19). Point-biserial correlations showed significant associations of psychological well-being with living away from family (rpb = 0.150, p = 0.04), having regular sexual partner (rpb = 0.057, p = 0.43), positive history of self-harm (rpb = -0.228, p = 0.002), positive history of suicidal ideation (rpb = -0.256, p <0.001), current self-perceived stress (rpb = -0.239, p <0.001), being MSM (rpb = 0.070, p = 0.33), being FSW (rpb = -0.154, p <0.01), being TW (rpb = 0.030, p = 0.686), and emotional intelligence score (rpb = 0.0296, p <0.001). Variables with correlation coefficients ≥ +0.1 or ≤ -0.1 were included in the multiple regression using the enter method. The results of multiple linear regression are shown in Table II. Overall, the model explained only a modest degree of variance with R-squared of 0.205. Residence away from family (β = 2.85; p = 0.038), history of suicidal ideation (β = -3.74; p = 0.022), and emotional intelligence (β = 3.25; p <0.001) were significant predictors of psychological well-being.

Figure 1: Sites of the CBOs working on the HIV prevention programmes for MSM, TW, and FSW in Pakistan, 2024.

A total of ten participants were interviewed in the qualitative part of the study. The sociodemographic statistics of participants are summarised in Table III.

Five themes and 13 subthemes were identified in thematic analysis. The themes showed some positive influence of CBO employment, as well as the challenges they bring.

Several participants from both groups of employees reported a positive effect of working at a CBOs on psychological well-being, mental health, and emotional intelligence. Participants stated that it enhanced their ability to empathise with people and gave a sense of satisfaction. In addition to adding a sense of purpose and connections, working in CBOs also reduces healthcare barriers for CBO workers and provides access to mental health services to those in need. During interviews, it also emerged that workers with less duration of employment had better psychological well-being and self-acceptance compared to those working for many years. However, it can be attributed to the positive social change that a decade of community activism has brought, as noted by one participant, while another interviewer attributed that to not being aware of the stressors faced by old CBO employees.

However, the participants also noted an alternative explanation for the improved psychological well-being of the CBO workers who were recently employed. They attributed it to less exposure to stress and community politics that old workers had to face, and new workers may face. However, the participant also noted a generally positive shift in the upcoming community generations due to education. Some of the participants also postulated that the effect of employment depends on personal attributes and varies from person to person, and CBO work brings no more stress or challenges than any other job. Other participants stated that CBO employment did not affect psychological well-being and emotional intelligence.

Participants stated that CBO employment added to their financial and social empowerment. It gave them an opportunity for professional growth. Newly recruited employees noted the support of their colleagues, which aided them in their growth. For FSW, working in the CBOs empowered them to resist intimate partner violence. A participant noted that her job had empowered her to resist intimate partner violence.

Employment in CBOs also facilitated self-acceptance and gender transition among TW. This empowerment — both social and financial, as noted by one participant — enabled greater confidence in the transitioning process compared to periods of unemployment.

CBO employment brings unique challenges that vary across individuals. Employees in smaller cities often face different challenges. The project-based nature of work, which is driven by targets, was reported as a significant source of stress. The salaries of CBO workers are often delayed as a result of late fund transfers from donors to recipients and workers, which adds to stress.

Another source of stress reported intracommunity toxicity, where employees’ gender identity and sexuality invalidated by peers. Rivalry and headhunting of employees within CBOs existed, which added to the stress faced by CBO workers.

DISCUSSION

Based on the results from this study, residence away from family and higher emotional intelligence were associated with better psychological well-being, whereas a history of suicidal ideation was associated with poor psychological well-being. Neither belonging to the MSM, TW, or FSW community predicted psychological well-being, nor did the duration of CBO employment significantly correlate with psychological well-being. However, the qualitative evidence pointed out that employment in CBOs and duration of employment both improve psychological well-being. Dafeeah et al. researched emotional intelligence among HIV health workers and attitudes towards HIV patients in Qatar. The study showed that emotional intelligence improved with years of work experience.¹² However, in this study, the key population status of the workers was not ascertained, and the participants were not based in a CBO.

Coulombe has concluded that the effect of life events on psychological well-being is moderated by the self-perceived valence attached to the change.¹⁶ This self-perceived valence differs from person to person. This qualitative analysis reinforces this concept, as participants stated that personal attributes define mental health. For some workers, the valence attached to CBO employment may be higher than for others, resulting in higher psychological well-being in these individuals. Tshisa et al. also reported that a queer supportive environment translated into improved emotional well-being among black queer individuals.¹⁷ Validating the environment was associated with positive well-being, both for heterosexual and lesbian, gay, bisexual, and transgender (LGBT) employees.^18-21 Fletcher et al. studied the role of supportive workplace practices for LGBT employees and their effect on life satisfaction. The study reported that supportive practices have a position impact on the life satisfaction of LGBT employees; however, this relationship is moderated by the centrality of LGBT identity.¹⁸ For individuals with a highly central LGBT identity, supportive practices had a positive impact on well-being and life satisfaction.¹⁸ Similarly, participants in these qualitative interviews have also noted that the impact of employment on well-being varies from person to person.

There is a plethora of literature that supports that emotional intelligence predicts psychological well-being as well as work performance. In one study from Australia, higher emotional intelligence among healthcare staff was related to better patient care.²² However, the authors are not aware of any study that explored the relationship between emotional intelligence and psychological well-being among MSM, TW, or FSW employees.

MSM and TW often face workplace discrimination and precarious employment globally, which can lead to poor well-being.^19,23 A national study from Canada has highlighted that gay and bisexual men are three times more likely to end up in vulnerable employment than heterosexual people.²³ While employment at CBO is validating for MSM, TW, and FSW, participants noted that insufficient sustainable funding is a perceived source of stress. The supportive environment of CBO also presents challenges. Community politics was identified as an additional source of stress.

To the best of the authors’ knowledge, this is the first study that examines the issue at hand. Two systematic reviews recently conducted on LGBT work experience and well-being show that the evidence base is largely from the Global North, with only two studies identified from India among the South Asian countries.^24,25 Thus, the study adds to the evidence base from South Asia and the Global South.

This is a cross-sectional study, only looking at the possible association between emotional intelligence and psychological well-being among MS, TW, or FSW employees. The sampling strategy of this study could have introduced selection bias as the employment at CBO passes through a stringent screening process. Individuals from marginalised communities hesitate to participate in research projects or disclose their identities, thereby those included in the study may not represent the study population. The environment of CBO is validating for MSM, TW, and FSW as a part of the institutional policy; thus, the results cannot be extrapolated to MSM, TW, and FSW working outside CBOs. Lastly, qualitative interviews may be subject to recall or interviewer bias.

CONCLUSION

Living away from family and having higher emotional intelligence positively predicted psychological well-being. A history of suicidal ideation was associated with poor psychological well-being. The quantitative analysis did not support any association between employment and psychological well-being; however, evidence from the qualitative interviews reveals that long-term employment in CBOs may improve psychological well-being of MSM, TW, and FSW. Key population status did not significantly predict psychological well-being.

ACKNOWLEDGEMENT:
The authors wish to acknowledge support from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH123256. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ETHICAL APPROVAL:
The study protocol was reviewed and approved by the Research Ethics Committee of the King Edward Medical University, Lahore, Pakistan (REC No. 09/IM/2023; Dated: 21-09-2023).

PARTICIPANTS’ CONSENT: 
Informed written consent was taken from the participants included in the study.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS' CONTRIBUTION:
UA: Design of the study, oversight of the project, data analysis, and preparation.
BF, SA, AM: Data analysis, preparation, and approval of the final manuscript.
MSK, RC: Preparation and approval of the final manuscript.
All authors approved the final version of the manuscript to be published.

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