Female sex workers in Laos : perceptions, care seeking behaviour and barriers related to sexually transmitted infection services

Abstract: Background: Sexually transmitted infections (STIs) cause health, social and economic burdens in both low- and high-income countries. Not only do STIs impact quality of life, reproductive health and child health, but they also play a crucial role in facilitating sexual transmission of human immunodeficiency virus (HIV). Prompt, correct diagnosis and treatment with health information are essential elements of STI and reproductive tract infection (RTI) services. In Laos, it is not known what makes female sex workers (FSWs) seek health care or what their priorities are when using public or private STI services. Other issues related to FSWs’ vulnerability, such as the social situation, work environment, and perceptions of health and ill-health are poorly understood and thus have rarely been considered when designing interventions. Aims: To explore FSWs’ perceptions of health/illness, and to assess their care seeking behaviours and risk perceptions as well as health care providers’ attitudes towards FSWs with STI symptoms in Savannakhet province in Laos. Methods: Semi-structured interviews regarding knowledge about STIs and attitudes towards FSWs with STI symptoms were performed with 244 health care providers (HCPs) providing STI services (I). Structured interviews about health seeking behavior were carried out with 407 FSWs (III). Both studies were carried out in 6 districts along Road 9, traversing Savannakhet province from Thailand to Vietnam. Descriptive statistics and chi-square test (I), and multiple multivariate logistic regression analyses were performed (III). Studies II and IV were conducted in Kaysone Phomvihan, the main district of Savannakhet province. Fifteen in-depth interviews were carried out with FSWs about what health and illness meant to them and what they believed signified good/bad health (II). Seven in-depth interviews and five focus group discussions were carried out with 39 FSWs (IV) about their working situation, risks related to their work, perceptions about how other people look upon FSWs, how to be accepted by the community, and how to cope with their situation. The qualitative data were analysed using latent content analysis (II, IV). Results: Fifty-four percent of HCPs had no STI training despite providing STI treatment. Misperceptions of STI causes, transmission routes, and symptoms were common among HCPs from both the public and the private health sectors. A higher proportion of pharmacists/drug sellers (68%) had negative attitudes followed by medical doctors/assistants (59%) and nurses/midwives (55%). The proportion of herbalists with negative attitudes (53%) was less in comparison with the other professionals (I). Eighty-six percent of the FSWs reported RTI/STI signs or symptoms currently or in the last 3 months but only two-thirds (67%) of those with symptoms sought treatment. The mean time of delay from onset of symptom to first visit to a healthcare agency was ten days. Source of treatment for the last RTI/STI episode was the drop-in centre (53%) followed by a public hospital (23%), private clinic (12%), private pharmacy (9%), and herbalist (2%). The main barriers to service use were long waiting time, inconvenient location of the clinic, not knowing where to get the services needed, and negative attitudes among healthcare providers. Care seeking behaviour was associated with longer duration of sex work (OR=2.6, 95%CI 1.52-5.36) (III). One main theme - ‘health is wealth and wealth is health’- emerged from the analysis in study II. Health was considered necessary in order to attract clients. On the other hand, money was needed in order to pay for treatment when sick and thus money was a prerequisite for health. FSWs perceived health as the ability to work and support their families while ill-health created social and economic vulnerability (II). The sex workers described their working situations, including their perceived risks. But they also talked about the benefits of sex work, as well as the strategies that they used to reduce risks and increase benefits (IV). The risks related to their work were: 1) STIs/HIV, 2) unintended pregnancy, 3) violence, 4) stigma, 5) being cheated, and 6) social and economic insecurity. The interviewed FSWs spontaneously reported three categories of benefits related to their work: 1) financial security and ways to increase income, 2) fulfilling social obligations, which increases self-value and 3) sexual pleasure. Conclusions: HCPs indicate limited knowledge about STIs. Furthermore, negative attitudes toward FSWs with STI symptoms were common among HCPs from both the public and private health sectors (I). FSWs sought care from both public and private health facilities. Barriers to accessing RTI/STI services were related to both structural and individual factors (III). Female sex workers’ beliefs and perceptions about health and ill-health were dominated by their economic need, which in turn was influenced by expectations and demands from their families (II). The obligation to support one’s family threatens FSWs’ health and social and financial security (II, IV). FSWs’ decision-making and risk taking behaviour were outcomes of risk-benefit analyses and were fueled by gender inequities and cultural and social norms that reinforce women’s lower social and economic status (IV). The FSWs were, however, not only victims. They also had some control over their lives and working environment, with most viewing their work as an easy and good way of earning money