|Year : 2014 | Volume
| Issue : 1 | Page : 23-28
Reproductive health problems and health seeking behavior of female sex workers in Sabon Gari Local Government Area, Zaria, Nigeria
LO Omokanye, AG Salaudeen, AS Yusuf
Departments of Obstetrics and Gynaecology, Epidermiology and Community Medicine, and Surgery, College of Health Sciences, University of Ilorin, Kwara, Nigeria
|Date of Web Publication||20-Mar-2014|
L O Omokanye
Departments of Obstetrics and Gynaecology, College of Health Sciences, University of Ilorin, Kwara
Source of Support: This project was jointly funded by the authors., Conflict of Interest: None
Background: The sexual and reproductive health needs of sex workers have been neglected both in research and public health interventions. Among the reasons for this are the condemnation, stigma and ambiguous legal status of sex work in Nigeria. This study was aimed at determining the reproductive health problems and health-seeking behavior of brothel-based female sex workers (FSW). Materials and Methods: This cross-sectional study was conducted among brothel-based FSW in Sabon-Gari Local Government in Zaria, Nigeria between 1 st January 2011 and 31 st June 2011. A total of 208 FSW were randomly selected and information was obtained with the use of the semi-structured questionnaire. Data entry was done with the help of structured codes in Microsoft Excel. Descriptive analysis was carried out using the statistical package (SSPS 16-University of Bristol). Results: Majority 90.7% of the respondents had experienced reproductive morbidity in the last 3 months. Frequently experienced symptoms were vaginal discharge (63.8%), acute lower abdominal pain (57.5%), menstrual irregularities (37%) and genital ulcer (32.3%). Genital tear occurred in only 25 (9.8%) respondents. Furthermore, 178 (63.6%) had a termination of unwanted pregnancies. Most (32.3%) sought care for their reproductive health problems from chemist shops; followed by the private hospitals in 23.6% of respondents. Others took self-medication for their ailments. Post-treatment success was the most frequently mentioned reason for the choice of place of treatment, followed by finance. Conclusion: The most commonly reported reproductive health problem among FSW was vaginal discharge and many of them have poor health seeking behavior. Health promotion and client sensitive health care services specifically targeting FSW should be developed, packaged and delivered to improve reproductive health of FSW. There should be concerted efforts by the government and other stakeholders in reproductive health to develop a policy framework to addressing the challenges in health of FSW.
Keywords: Brothel-based, female sex workers, health problem, reproductive
|How to cite this article:|
Omokanye L O, Salaudeen A G, Yusuf A S. Reproductive health problems and health seeking behavior of female sex workers in Sabon Gari Local Government Area, Zaria, Nigeria. Sahel Med J 2014;17:23-8
|How to cite this URL:|
Omokanye L O, Salaudeen A G, Yusuf A S. Reproductive health problems and health seeking behavior of female sex workers in Sabon Gari Local Government Area, Zaria, Nigeria. Sahel Med J [serial online] 2014 [cited 2022 Oct 6];17:23-8. Available from: https://www.smjonline.org/text.asp?2014/17/1/23/129150
| Introduction|| |
A sex worker (SW) is defined as someone who engages in sexual activity, for financial and/- or other benefits.  Although men and transgender individual are also involved in this work, women form the majority among SWs and are referred to as female sex workers (FSW). The FSW from low-income strata are being driven into this profession mainly by poverty, with one or more men behind this decision.  They are exposed to various perils such as health problems, violence, criminal behavior, exploitation and marginalization.
There is growing recognition of the need to strengthen the linkages between reproductive health and human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention services for FSW. , This is especially important in regions where HIV is predominantly spread through heterosexual and vertical transmission and where unprotected sex between FSWs and their clients are key drivers of HIV epidemic.  Until date, research and interventional programs have primarily focused on the burden of and vulnerability to, STIs and HIV in FSWs. , Meeting the FSWs' need for reproductive health and STIs/HIV prevention is critical given their high rates of unintended pregnancy, , as well as high rates of HIV and STIs.
The most common morbidity prevalent among women of reproductive age group are painful intercourse, upper/lower reproductive tract infections (RTI), upper/lower urinary tract infections, menstrual problems and prolapse of the uterus.  An ethnographic study of FSWs in Calcutta revealed that menstrual problems were found in 33.0% of FSWs, upper RTI in 26.0%, lower urinary tract infections in 11.0%, leucorrhoea in 7.0% and lower RTI in 7.0%.  Poor hygiene, unsanitary living conditions associated with poverty and limited access to well-trained health care providers all further, increased women's exposure to RTI.  Prevalence of human papilloma virus (HPV) infection was high among women who did not practice genital hygiene. , Promiscuity was also found to be a significant factor for RTI. The presence of HPV increases the vulnerability of women to various genital tract malignancies. ,
A study in Tamil Nadu revealed that 65.0% of women who had symptoms of RTI never sought any kind of health care.  Women were reluctant to seek medical treatment due to lack of privacy, lack of a female doctor at the health facility, low decision-making power and subordinate social status. Another study in Côte d'Ivoire indicated financial barriers to be the main reason for not visiting a public health center when experiencing health problems.  Special clinics for FSWs carried some stigma and also gave the police an opportunity to trace them.  Alcoholism, drug abuse and related problems were rampant among FSWs. These factors increase the vulnerability of the FSWs and result in an increased morbidity among such women. ,
Various programs on FSWs address their sexual health needs and ignore the reproductive and other health aspects like the general health and mental health.  They also concentrate on condom promotion strategies, STI testing and treatment.  Lack of information appears to be a major barrier to general health care seeking behavior. , Some women do not even know where to get general health care while others knew where to get care but their health was placed low on their list of priorities.  Many do not have health insurance or other medical aid and do not know how to obtain it.  Thus arises the need to study the reproductive health problems and health-seeking behavior of FSW in our locality.
| MaTerials and Methods|| |
This cross-sectional study to identify the reproductive health problems and health-seeking behaviors was conducted among brothel-based FSW in Sabon-Gari Local Government, Zaria; Kaduna State, Nigeria between 1 st January 2011 and 31 st June 2011. Sabon-Gari Local Government in Zaria is a semi-urban community located in the North Western Nigeria. It is a cosmopolitan setting occupied by many ethnic groups in Nigeria. The common tribes were Hausa, Yoruba and Ibo. The major occupation of the inhabitants was trading and the community played host to a large number of commercial activities. Zaria city also serve as commercial linkage to other major cities in the North Western Nigeria. Study population consisted of women, in the defined reproductive age group (15-45), who were currently active SWs.
The minimum sample size for this study using Fischer's formula was 254, however to cater for attrition the desired sample size was 280. There were 33 brothels in the LGA, out of which 20 were randomly selected. Equal allocation of respondents was done for recruitment in to the study, i.e. 14 FSWs in each selected brothel. Simple random sampling was adopted to select 14 consenting FSWs in each brothel. Four research assistants who are versed in three major languages namely; Hausa, Ibo, Yoruba were trained for 2 days by researchers for the purpose of questionnaire administration. A semi-structured questionnaire with mostly closed and a few open-ended questions was administered to them by the research assistants. The questionnaire contains information on reproductive health problems, i.e. reproductive health morbidity and symptoms suffered in the last 3 months, place of treatment of health problem, current preventive practices among others. Pre-testing of the questionnaire was done in one of the brothels in the city to check the clarity and practicality of the questions used. Necessary modifications were made to meet the objectives. The questionnaire, made in English was thoroughly translated to Hausa, Ibo or Yoruba depending on the choice of the respondents and explained to them in a manner they understood. FSWs were met before the actual data collection a couple of times and rapport was built. They were then approached at their worksites-the brothels/-lodges/peer's houses. They were interviewed at a time convenient for them. Each interview took 20-30 min and data was collected by investigators.
Informed consent was taken from FSWs individually and strict confidentiality was maintained. They could refuse to participate in the study at any point during the study without any adverse implications. For those who were willing to participate but not willing to sign the consent, oral consent was taken in the presence of a third person available and acceptable to the interviewee. Ethical approval was obtained from the department of Epidemiology and Community Health of University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria.
Data entry was done with the help of structured codes in Microsoft Excel. Data validation was done to check for errors in data entry. Descriptive analysis was carried out using the statistical package (SPSS 11.0 version for windows).
| Results|| |
The average age of the respondents was 30 years (standard deviation [SD] ±5.7 years); 15% of them were below 25 years of age and 45% were above 35 years. About 10.0% were married while majority 86% were unmarried; and 4% were divorced/separated. 56 (20%) of respondents were illiterate; 96% consumed alcohol, 2.8% were addicted to other substances, and 78.5% smoked cigarette.
Mean age of their first penetrative sexual encounter was 15.4 years (SD ± 2.5 years). 20% of them have been in the profession for >10 years while 28% had <5 years' working experience. Poverty or financial reasons such as unemployment of family members (primary income earner), alcoholism of spouse/father, sudden loss of the earning member, and debt pushed 98% of respondents into the profession; 2% were forced into this profession by family members.
Majority (70%) of them practiced sex work in several towns simultaneously; however, 15% worked within Zaria town, 12% preferred the neighboring town and 3% operated in tourist places. Majority (90%) were involved in the work full-time; while for 10%, it was a part-time job. For those that worked part-time, other professions they engaged in include construction work (35%), agricultural work (45%), petty trading (10%), and other work (10%).
Two-third of the respondents worked for >20 days a month while one-third worked for <10 days. Mean monthly income from sex work was estimated at 50,000 Naira ($313). On an average, each FSW served three paying clients and one non-paying client per day. Clients were of two types - paying and non-paying; non-paying clients were their pimps/managers. Almost all of them (95%) provided services for both paying and non-paying clients while 5% provided services exclusively to paying clients.
[Table 1] shows the reproductive health problems of the FSWs. 244 (90.7%) out of the 280 respondents interviewed, majority 254 (90.7%) had experienced reproductive morbidity in the last 3 months while 26 (9.3%) did not. The most frequently experienced symptoms were vaginal discharge in 162 (63.8%) of respondents, acute lower abdominal pain in 146 (57.5%), menstrual irregularities in 94 (37%) and genital ulcer in 82 (32.3%) respectively. Genital tear occurred in only 25 (9.8%) of respondents. About two-thirds, 178 (63.6%) of the women have had termination of unwanted pregnancies. 76 (42.7%) of them had two terminations while only 6 (3.4%) had one termination of pregnancy.
[Table 2] shows health-seeking behavior of FSWs. Of those that had reproductive health problems most 82 (32.3%) sought care for their reproductive health problems from chemist shops, followed by (23.6%) from private hospitals and (21.3%) had self-medication. Only thirty (11.8%) respondents were treated in the government hospital while some 28 (11%) were treated by their friends. Majority 164 (92.1%) of unwanted pregnancies were terminated at the private clinics, followed by 10 (5.6%) at home and 4 (2.2%) at government hospitals. 114 (44.9%) reported that post-treatment success was the reason for the choice of place of treatment, followed by financial reasons in (30.7%) of women. The severity of symptoms (19.5%), stigma (18.9%) and privacy (18.1%) were the other reasons given for the choice of place of treatment.
Some preventive measures against STIs currently adopted by the FSWs include: Use of condom in 270 (96.4%) respondents, washing of genital after sexual intercourse in 71.4% of them, and refusal of clients suspected to have STIs by 64.3%. Other measures include hepatitis B vaccination in 7.1% and other methods of family planning in 10.7% of respondents [Table 3]. [Table 4] showed pattern of condom use among FSWs. Most of them (60.7%) use condom occasionally, (35.7%) always use condom while (3.6%) never use condom. Condom use was commoner among FSWs with secondary level of education 130 (46.4%) while only (20%) of respondents with no formal education use condom. With increasing level of education there was increase in condom use [Table 5]. Reasons for irregular use of condom were customer dislike 144 (84.7%), unavailability of the condoms 18 (10.6%) and cost 2 (1.2%).
| Discussion|| |
All respondents were within 18-38 years with a mean age of 30 years; this is a sexually active age group and a similar study conducted in Abidjan revealed a mean age of 26 years among FSW.  Only 10% of the respondents in this study were married, this is contrary to 87% reported in Bangalore.  In Nigeria, female commercial sex work in most circumstances is not compatible with marriage as the occupation is unacceptable to male partners. Most of the respondents, 96% consumed alcohol, 78.5% smoked a cigarette while 2.8% were addicted to other substances; this concur with study in Bangalore where all FSW consumed alcohol and 74% were smokers.  Alcohol use was positively associated with adverse physical health, illicit drug use, mental health problems and victimization of sexual violence among FSW.
This study revealed that poverty or financial reasons such as unemployment of family members, alcoholism of spouse/father, sudden loss of the earning member, and debt pushed 98% of the respondents into the profession; 2% were forced into this profession by family members. This is similar to findings in Thailand where it has been shown that women's ability and decisions to engage in sex work were determined primarily by four factors: economic situation, relationship with a steady partner, attitudes toward sex work and HIV/acquired immunodeficiency syndrome (AIDS) experience.  Economic concerns, ranging from survival needs to materialistic desires, had the strongest influence. This underscores the need for the government at various levels to expand the scope of poverty alleviation program and be more focused in implementation to ensure citizen benefit maximally from it.
Two-thirds of FSW worked for >20 days a month while one-third worked for <10 days. This is because about 90% were involved in the sex work on full time basis and some of them often travel from one place to another in search of customer based on bagging power. The situation is worse in Peru where some of the FSW were engaged in sex work for 6 days/week.  The mean monthly income from sex work was estimated at 50,000 ($313). This clearly demonstrated that poverty is the main driver to sex work. On an average, each FSW served three paying clients and one non-paying client per day. The non-paying partner will keep them on the job and sometimes provide network of customers to them. This is in consonance with findings in a similar study in Ethiopia and Southern India. ,
Majority (90.7%) of the women had experienced morbidity related to their reproductive tract in the last 3 months. Frequently experienced symptoms were vaginal discharge (63.8%), acute lower abdominal pain (57.5%), menstrual irregularities (37%) and genital ulcer (32.3%). Genital tear was reported by 9.8%. These reproductive health problems are common in women and a similar study has revealed that 30% of FSW reported symptoms of STI within a period of 4 weeks. 
About one-third (32.3%) of the respondents sought care for their reproductive health problems from patent medicine vendors and only 11.8% were treated in the government hospital. Post treatment success was the most (44.9%) frequently mentioned reason for the choice of place of treatment; others were finance (30.7%), severity of symptoms (19.5%), fear of stigma (18.9%) and privacy (18.1%). In a similar study in Abidjan, finance and health worker relationship positively influence the choice of place of treatment,  this underscores the relevance of financial status and inter-personal relationship in health care service delivery. Health is a priority for any human being and this is not different among FSW because it is only a healthy individual that can be involved in any commercial activity, sex work inclusive.
The major preventive measure adopted by the FSW was use of condom (96.4%), More respondents with secondary education currently used condom compared with people of lower or no formal education, the observed difference was statistically significant (P = 0.0000). These measures are in line with STI prevention; however, the proportion of respondents engaged in these preventive approaches may not be adequate to abate the spread of HIV and other RTI.
It is well-recognized that sexual and reproductive ill-health and HIV/AIDS share root causes; including poverty, gender inequality and social marginalization of most vulnerable group (FSWs). Therefore, there should be concerted efforts by the government and other stakeholders in reproductive health to develop a policy framework to addressing the challenges in health and socio-economic of FSWs.
| References|| |
|1.||Alexander P. Health care for sex workers should go beyond STD care, research for sex work 2, 1999. Available from: http://www.hcc.med.vu.nl/artikelen/alexander2.htm. [Last accessed on 2013 June 10 ]. |
|2.||Chacham AS, Diniz SG, Maia MB, Galati AF, Mirim LA. Sexual and reproductive health needs of sex workers: Two feminist projects in Brazil. Reprod Health Matters 2007;15:108-18.
|3.||Wayal S, Cowan F, Warner P, Copas A, Mabey D, Shahmanesh M. Contraceptive practices, sexual and reproductive health needs of HIV-positive and negative female sex workers in Goa, India. Sex Transm Infect 2011;87:58-64. |
|4.||Moses S, Blanchard JF, Kang H. AIDs in South Asia: Understanding and Responding to a Heterogeneous Epidemic. Washington, DC, USA: The World Bank; 2006. |
|5.||Cwikel JG, Lazer T, Press F, Lazer S. Sexually transmissible infections among female sex workers: An international review with an emphasis on hard-to-access populations. Sex Health 2008;5:9-16. |
|6.||Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of HIV among female sex workers in low-income and middle-income countries: A systematic review and meta-analysis. Lancet Infect Dis 2012;12:538-49. |
|7.||Swain SN, Saggurti N, Battala M, Verma RK, Jain AK. Experience of violence and adverse reproductive health outcomes, HIV risks among mobile female sex workers in India. BMC Public Health 2011;11:357. |
|8.||Khan MR, Turner AN, Pettifor A, Van Damme K, Rabenja NL, Ravelomanana N, et al. Unmet need for contraception among sex workers in Madagascar. Contraception 2009;79:221-7. |
|9.||Gosalia VV, Verma PB, Doshi VG, Singh M, Rathod SK, Parmar MT. Gynaecological morbidities in women of reproductive age group in urban slums of Bhavnagar city. Natl J Community Med 2012;3:657-60. |
|10.||Evans C, Lambert H. Health-seeking strategies and sexual health among female sex workers in urban India: Implications for research and service provision. Soc Sci Med 1997;44:1791-803. |
|11.||Rahman M, Alam A, Nessa K, Hossain A, Nahar S, Datta D, et al. Etiology of sexually transmitted infections among street-based female sex workers in Dhaka, Bangladesh. J Clin Microbiol 2000;38:1244-6. |
|12.||Cherian V. Prevalence and determinants of human papilloma virus (HPV) infection in Kerala, India. [M. Phil Thesis], University of Tampere. Reproductive Health Practices and Health Seeking Behaviour of Female Sex Workers in Tamil Nadu; 2000. |
|13.||Apte H, Agarwal S. Personal hygiene and self reported symptoms suggesting UTI and RTI among 100 women in Pune city. AIDS 1999;2:37. |
|14.||Prasad JH, Abraham S, Kurz KM, George V, Lalitha MK, John R, et al. Reproductive tract infections among young married women in Tamil Nadu, India. Int Fam Plan Perspect 2005;31:73-82. |
|15.||Vuylsteke B, Ghys PD, Mah-bi G, Konan Y, Traor, M, Wiktor SZ, et al. Where do sex workers go for health care? A community based study in Abidjan, Côte d'Ivoire. Sex Transm Infect 2001;77:351-2. |
|16.||Wolffers I. Appropriate health services for sex workers, research for sex work 2, 1999. Available from: http://www.hcc.med.vu.nl/artikelen/wolffers2.htm. [Last accessed on 2013 May 13]. |
|17.||Baker LM, Case P, Policicchio DL. General health problems of inner-city sex workers: A pilot study. J Med Libr Assoc 2003;91:67-71. |
|18.||Manopaiboon C, Bunnell RE, Kilmarx PH, Chaikummao S, Limpakarnjanarat K, Supawitkul S, et al. Leaving sex work: Barriers, facilitating factors and consequences for female sex workers in northern Thailand. AIDS Care 2003;15:39-52. |
|19.||Pandiyan K, Chandrasekhar H, Madhusudhan S. Psychological morbidity among female commercial sex workers with alcohol and drug abuse. Indian J Psychiatry 2012;54:349-51. |
|20.||Kohler P, Campos PE, Buendia C, Carcamo C, Garcia PJ, Hughes J, et al. Health-seeking Behaviors among Female Sex Workers in a Community Randomized Trial in Peru (The Peru-PREVEN Study). International Society for Sexually Transmitted Diseases Research (ISSTDR); 2011. p. 1-10. |
|21.||Mooney A, Kidanu A, Bradley HM, Kumoji EK, Kennedy CE, Kerrigan D. Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia. BMC Public Health 2013;13:771. |
|22.||Deering KN, Bhattacharjee P, Mohan HL, Bradley J, Shannon K, Boily MC, et al. Violence and HIV risk among female sex workers in Southern India. Sex Transm Dis 2013;40:168-74. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]