|Year : 2021 | Volume
| Issue : 3 | Page : 244-252
Grassroots sexual and reproductive rights interventions on sexual risk behavior among female sex workers in Nigeria
Bartholomew B Ochonye1, Paul O Abiodun2, Felix O Sanni3, Olufunke Tewobola1, Tolu A Alamu1, Ngozika Ogbonna1
1 Department of Leadership and Administration, Heartland Alliance International, Abuja, Nigeria
2 Department of National Integrated Specimen Referral Network, AXIOS International, Utako, FCT, Abuja, Nigeria
3 Public Health Department, Triune Biblical University Global Extension, NY, USA
|Date of Submission||29-Jun-2021|
|Date of Acceptance||22-Jul-2021|
|Date of Web Publication||03-Sep-2021|
Dr. Bartholomew B Ochonye
Department of Leadership and Administration, Heartland Alliance International, Abuja.
Source of Support: None, Conflict of Interest: None
Introduction: Sexual reproductive health and rights (SRHR) involve access to accurate information, rights-based quality, safe, effective, affordable, and acceptable health-care services at all levels that cover the sexual and reproductive needs of the individual and community irrespective of social, sex, gender, and other differences. Objective: This study aims at assessing the grassroots interventions on the knowledge of rights, access, and uptake of sexual reproductive health (SRH) services among female sex workers (FSWs) in Benue State, Nigeria. Materials and Methods: This cross-sectional survey is a randomized cluster sampling among FSWs in Benue State, Nigeria. A structured questionnaire was used to collect data from the respondents, and the data collected were analyzed using IBM-SPSS Corp., Armonk, NY, version 25.0. The statistical significance level was set at P < 0.05. Results: Respondents were 446 FSWs aged 15–45 years, comprising 223 FSWs at baseline and post-intervention. Significantly higher intervention respondents (84.4%) use condoms while drunk compared with 56.1% at the baseline (P < 0.0001). Overall, 70.0% used lubricants in the past 12 months in the post-intervention study, whereas only 47.5% used them in the baseline study (P < 0.0001). Generally, 21.1% indulged in anal sex, and there was no significant difference between the baseline and intervention (P > 0.05). Virtually all respondents (96.0%) used any contraceptive methods in the intervention period compared with 68.6% at the baseline (P < 0.001). The intervention respondents were 11.84 (95% CI: 4.98–28.16; P < 0.0001) times more likely to use any contraceptive method than their baseline counterparts. The intervention respondents were 2.22 (95% CI: 1.51–3.27; P < 0.0001) times more likely to use emergency contraceptives than their baseline counterparts. Conclusion: This study showed the positive outcomes of grassroots interventions involving FSWs in Benue State, Nigeria. Such interventions should be extended to other key populations in Nigeria.
Keywords: Contraception, grassroots intervention, sex workers, sexual behavior
|How to cite this article:|
Ochonye BB, Abiodun PO, Sanni FO, Tewobola O, Alamu TA, Ogbonna N. Grassroots sexual and reproductive rights interventions on sexual risk behavior among female sex workers in Nigeria. MGM J Med Sci 2021;8:244-52
|How to cite this URL:|
Ochonye BB, Abiodun PO, Sanni FO, Tewobola O, Alamu TA, Ogbonna N. Grassroots sexual and reproductive rights interventions on sexual risk behavior among female sex workers in Nigeria. MGM J Med Sci [serial online] 2021 [cited 2022 Jan 25];8:244-52. Available from: http://www.mgmjms.com/text.asp?2021/8/3/244/325546
| Introduction|| |
The SRHR involves access to affordable health-care services and use at all levels. The population (clients or patients), including FSWs, needs to be well informed about SRHR’s benefits and relevance to the family, community, and state at large. With the advancement of information and communication technology, birth control, sexually transmitted infections (STIs), human immunodeficiency virus infection/acquired immune deficiency syndrome (HIV/AIDS), latest clinical research, medicines, and data availability, a significant part of the population is aware of SRHR and services such as contraception, HIV/AIDS, and STI service delivery. New technology has been used in initiatives/interventions to promote wellness and behavioral improvement.,,, The availability of SRHR education, information, and communication (IEC) materials in public places, grassroots, and brothels worldwide has increased individual awareness and acceptability.
The World Health Organization (WHO) describes sex work as exchanging sex for money and materials. Sex workers may be males, females, or transgender individuals who consciously identify what they do to generate income, even though they do not regard it as a profession.
In Nigeria, most sex workers do not consider themselves at risk of any infection, and at most times, they justify and defend their risky activities. This perception is a common psychological reaction to their worries, challenges, and anxiety resulting from differences between views and actions. To minimize this conflict, a large proportion of FSWs firmly agree to the existence of HIV, destiny, and faith-based protection.
Heartland Alliance International (HAI) runs a grassroots intervention project in Nigeria with support from the Kingdom of the Netherlands titled “Sexual and Reproductive Rights for All, SARRA.” SARRA is an inclusive, intersectional human right and movement-building initiative with reproductive health knowledge and resources to cover 8000 marginalized women and girls. Some of the grassroots interventions being executed by HAI through SARRA in Nigeria include sensitization of FSWs, women with mental and physical challenges, and female drug users (FDUs) on SRHR issues, screening and treatment of HIV and other STIs through the community-led medical outreach, provision of family planning commodities and services to FSWs, women with disabilities, and FDUs, as well as distribution of condoms and sanitary products (dettol, sanitary pads, tissue papers, detergents), to program participants and many other programs.
The majority of research and public health interventions are centered on STI/HIV management, whereas the sexual and reproductive health needs of sex workers are neglected. One explanation for the neglect of sexual and reproductive health needs of sex workers is criticism, stigma, and unclear legal status of sex work, especially in Nigeria. Meeting the SRH needs of FSWs depends on supporting their human rights, access to health services without prejudice, and commitment to psychosocial health, alcohol and substance abuse, customer, partner, pimp, and police harassment. Therefore, this study aimed at assessing the effects of grassroots sexual and reproductive rights interventions on sexual risk behaviors among FSWs in Benue State, Nigeria.
| Materials and methods|| |
This study is a cross-sectional quantitative study that assessed grassroots intervention on the risky sexual behaviors of FSWs in Nigeria. The study used randomized cluster sampling.
Study location and population
The sample frame of this study is female sex workers in Benue State, Nigeria. The study was conducted in six local government areas (LGAs). They are Makurdi, Gboko, Ukum, Katsina-Ala, Konshisha, and Buruku. The sites were randomly selected for the study by using a random number generator. The study population comprised female sex workers across the six selected LGAs.
Sexual and reproductive rights for all interventions
In Nigeria, Heartland Alliance International runs a project with support from the Kingdom of the Netherlands titled “Sexual and Reproductive Rights for All (SARRA).” SARRA is an inclusive, intersectional human right and movement-building initiative with reproductive health knowledge and resources to cover 8000 marginalized women and girls. HAI builds the capacity of grassroots organizations to implement this project—the Mistletoe Community Health and Rights Initiative (MCHARI) in Lagos and the Global Women’s Health, Rights, Empowerment Initiative (GWHREI) in Benue, which are best placed to mobilize their peers on SRH issues and ultimately call on national and global policymakers and service providers to mobilize their peers on SRH issues in line with the Netherlands’ human rights policy of “Justice and Respect for All”; this project empowers marginalized women, regardless of social status, sexual orientation, and gender identity, to secure their sexual and reproductive health and rights. Many who live with disabilities participate in transactional sex, and those who use drugs and alcohol are part of the oppressed women mobilized within this initiative.
SARRA pilots and documents promising practices to promote the rights of these marginalized communities in the course of its implementation, develop the foundation for locally driven advocacy, and launch models for enhanced collaboration between SRH services to be scaled up in the future. In Nigeria, since 2008, HAI has been at the forefront of the country’s efforts to stop the HIV/AIDS epidemic among the main population (K.P.), “green housing,” a variety of KP-led organizations, notably drug users, sex workers, and LGBT organizations that are actively engaged in service delivery.
Through SARRA, some of the programs of Heartland Alliance International include: (1) sensitization FSWs, FDUs, and women with mental and physical challenges about their rights to sexual and reproductive services; (2) provision of screening and treatment for STIs to women through community-led medical outreach; (3) provision mental health and psychosocial services for sex workers and women who use drugs; (4) provision of family planning commodities and services to FSWs, women with disabilities, and female drug users; (5) distribution of condoms and sanitary products (dettol, sanitary pads, tissue papers, detergents) to program participants identified; (6) provision of gender-based violence (GBV) response services for women and girls who have experienced violence; (7) mobilization of GBV support groups to host community exchanges in a safe space, and share experiences and promote each other’s skills to prevent, identify, and respond to violence.
The interventions were carried out across Benue State after the baseline survey conducted in October 2018. The implementation of the interventions involved all identified brothels in the State in November 2018 and was supposed to last for 24 months. Data collection for the current study was done in these brothels in six LGAs in December 2020, meaning that all respondents in this study were involved in the interventions.
Sample size determination
The sample size was determined based on the estimated population size of FSWs (15,000) in Benue State, Nigeria, with a 7% margin of error. Alpha was set at P = 0.05 and 95% confidence for the null hypothesis. Using the formula
where N is the population size of FSWs in Benue State = 15,000, Z2 = z is z score at 95% confidence interval = 1.96, P = response proportion set at 50% = 0.5, 1−P = 1−0.5 = 0.5, and e = marginal error = 7% = 0.07.
The minimum estimated sample size was 426, with 213 from each baseline and post-intervention. The sample size was calculated at the baseline study, so the post-intervention sample size was determined based on the baseline calculation to allow for comparative analysis.
A cluster time-location sampling method was used. Sex worksites (which have already been mapped with estimated numbers of potential participants) in the state were randomly selected using a random number generator. All FSWs present in the sites when the investigators visit them and who provide informed consent were interviewed. Interviews were conducted in private spaces in the sites or, if not available, in tents provided by the program.
Data collection instruments
Structured questionnaires were used in collecting data from the respondents. The instrument was designed in the English language, and local dialect as applicable, wherein the questions were cross-checked to verify the context. Trained research assistants administered the questionnaires. The tool was pretested in the Federal Capital Territory, Abuja, and necessary adjustments were made before going for the field survey. The pretested questionnaire for baseline was also used for data collection during the post-intervention survey.
Inclusion and exclusion criteria
All FSWs aged 15 years and older and who had participated in the intervention program for at least one year were involved, whereas those who did not meet the inclusion criteria were excluded.
The completed data were coded, and the IBM-Statistical Package did the data analysis for Social Sciences (IBM-SPSS) version 25.0 for Windows IBM Corp., Armonk, NY. The analyses were all categorical and included point estimates and confidence intervals for descriptive data and chi-square/logistic regression (with generalized estimated equations to account for the cluster effect). The statistical significance level was set at P < 0.05.
The ethical research clearance was sought and obtained from the National Health Research Ethics Committee of Nigeria (NHREC) with approval number NHREC Protocol Number NHREC/01/01/2007–08/03/2019. Approval was also obtained from Heartland Alliance International to use its baseline data. All information obtained from the respondents is kept confidential and only used for the study. The study procedure was explained to each participant, and written consent was obtained from them before administering the questionnaire. Data that can be used to identify the respondents were not collected.
| Results|| |
The sociodemographic profiles of FSWs interviewed in Benue State are shown in [Table 1]. Their age distribution indicates that only 12.8% were within the ages 15–19 years whereas 33.4% were within 25–29 years. About one-fifth (23.3%) had no formal education, 27.6% had primary education, and 39.9% attained secondary education. The majority of the respondents (59.0%) were single and were mostly (91%) Christians. About three of five (62.2%) said they spent between 1000 and 5000 naira daily. Respondents also commented on the membership of village savings and loan groups as well as support groups. Most of them (73.1%) did not belong to any saving and loan groups, whereas 57.6% belonged to some support groups.
Risky sexual behaviors of female sex workers in baseline and after the interventions
Various sexual behaviors of FSWs were investigated at the baseline and intervention to discover the outcomes of the grassroots interventions.
Use of condoms and lubricants during sex
Most (58.1%) of the respondents used condoms during sexual intercourse. Overall, more than half (58.7%) of the participants used lubricants during sexual intercourse. Nevertheless, 70.0% of the intervention respondents used lubricants in the past 12 months against 47.5% in the baseline study (P < 0.0001) [Table 2].
|Table 2: Sexual behaviors of FSWs in baseline and after the intervention|
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Generally, about one out of every five respondents (21.1%) indulges in anal sex. [Table 2] shows no significant difference whatsoever between respondents at the baseline and those of the intervention.
Respondents’ knowledge and use of contraceptives
The general knowledge about the use of contraceptives among FSWs was high in both surveys (92.4%). All respondents in the intervention said that they knew any contraceptives compared with 84.8% of the respondents in the baseline study, as shown in [Table 3]. The post-intervention research indicated that the knowledge of all contraceptives was significantly higher than the baseline (P < 0.0001). The knowledge of oral contraception was substantially higher (85.2%) in the post-intervention group as compared (54.3%) in the baseline study (P < 0.001). The knowledge of injection and implant contraceptive methods also significantly rose to 87.9% and 91.9% after the interventions from 27.4% and 21.5%, respectively (P < 0.001) [Table 3].
|Table 3: Use of contraceptives among FSWs at baseline and post-intervention|
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Use of contraceptives in the past 12 months
[Table 3] also shows that most (86.3%) of the total respondents used contraceptives in the past 12 months. Almost all the respondents (97.3%) in the post-intervention survey used contraceptives against three-quarters (75.3%) of the respondents in the baseline group. Condom tops the list of contraceptives used by respondents though higher for intervention (91.0%) compared with 70.0% in the baseline group. The use of oral contraceptives fell from 43.0% in the baseline group to 30.3% in the intervention group. The use of an implant, however, increased significantly from 8.1% in the baseline group to 22.9% in the intervention group.
Virtually, all respondents (96.0%) are currently using any of the contraceptive methods in the intervention survey compared with 68.6% of respondents in the baseline study (P < 0.001). [Table 3] also shows that respondents, in both the baseline and intervention groups, currently use condoms as the most preferred contraceptive, although a higher proportion (89.2%) for the intervention study compared with 63.2% for the baseline study. Second in rank to condoms is oral contraceptives, with one-third (33.2%) of respondents currently using oral contraception in the baseline group, which is relatively higher than 24.2% of respondents in the intervention group (P = 0.036).
Respondents aired their opinions about the use of contraceptives. About three-quarters (72.6%) of them were comfortable using contraceptives. However, about three-fifth (65.5%) of the respondents in the baseline group were satisfied using contraceptives compared with a higher proportion (72.6%) in the intervention group, as shown in [Table 3] (P < 0.001).
Half (50.7%) of the respondents in the baseline group admitted that they ever used emergency contraception compared with 69.5% of respondents in the intervention group. The FSWs with interventions were 11.84 (95% CI: 4.98–28.16; P < 0.0001) times more likely to use any contraceptive method than their baseline counterparts; 10.88 (95% CI: 5.27–22.45; P < 0.0001) times currently using any contraceptives more than their counterparts before intervention; and 2.09 (95% CI: 1.36–3.20; P = 0.0001) times more comfortable using contraceptives than their baseline counterparts. Also, FSWs with interventions were 2.22 (95% CI: 1.51–3.27; P < 0.0001) times more likely to use emergency contraceptives than their baseline counterparts. The FSWs with interventions were 3.55 (95% CI: 2.34–5.38; P < 0.0001) times more likely to have been tested for any STIs in the past 12 months than their baseline counterparts and 0.27 (95% CI: 0.12–6.14; P = 0.002) times less likely to have been tested for HIV in the past 12 months than their baseline counterparts, as shown in [Table 4].
|Table 4: Logistic regression of baseline and intervention findings of the uptake of SRH services|
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| Discussion|| |
Despite the high risk of adverse SRH outcomes among FSWs in low-resource countries such as Nigeria, they still have low access to SRH services. Therefore, this study was carried out to assess the grassroots interventions on the awareness of FSWs of right to SRH services, sexual behavior, gender-based violence experience, uptake of SRH services, and satisfaction with communication and services received from health-care facilities. Similar to the baseline survey, an equal number of FSWs were randomly selected from the population involved in the SARRA program for post-intervention surveys.
More than 60% of the FSWs in both the baseline and post-intervention studies were young adults aged 20–29 years and never married (61.4%), whereas an unacceptably high proportion (12.8%) were adolescents (10–19 years). Besides, about half only attained primary education and were mostly Christians. These findings are similar to what were obtained in a multicountry study of the uptake of SRH services among FSWs by Lafort et al. in which the majority were between ages 20 and 30 and never married. A similar age bracket was also reported in several other studies involving FSWs in Nigeria and beyond,,, implying that the family and societal value system has eroded the social protection for adolescents and young people and is further exacerbated by inadequate education, especially among adolescent women and girls.
Sexual risk behaviors and the preventive measures of the female sex workers
Use of condoms and lubricants
One of the community services suggested by the WHO is the distribution of condoms and lubricants to FSWs and men who have sex with men, because the use of condoms and lubricants is essential for the prevention of HIV/AIDS among the critical population. To prevent the spread of HIV among FSWs in Benue State, SARRA embarked on sensitization programs for both the FSWs and health-care providers on condom efficacy. The proportion of FSWs who did not use condoms during sex with their partners while drunk was significantly higher (43.9%) among FSWs in the baseline study than (15.6%) in the intervention study. Regarding the frequency of condom use with their sexual partners, there was no significant difference between the baseline and intervention respondents. However, the rate of sex without a condom found in this study is lower than that (56.4%) reported in China. The reduction in the level of sex without condoms seen in this study can be attributed to the interventions. Similarly, another study conducted among adolescent FSWs also reported that inconsistent use of condoms was 65%, and 10 of 74 respondents who used condoms consistently failed to use condoms while drunk in one month.
In this study, a significantly higher proportion (70.0%) of FSWs at the post-intervention used lubricants during sex than 47.5% at the baseline. This finding indicates better awareness of sexual risks, which can be attributed to grassroots interventions. A study conducted in four African countries (Kenya, Zimbabwe, Uganda, and South Africa) shows insufficient access to condoms and lubricants as part of their unmet needs of FSWs, and even, a large number had never seen lubricants or understood its purpose. This report was from a study not involving any intervention. The higher proportion of FSWs who had used lubricants during sexual activities in the past 12 months in this study can be considered one of the positive outcomes of the grassroots interventions by SARRA in Benue State. SARRA provides SHR services such as the distribution of condoms, contraceptives, and lubricants. The poor use of lubricants among FSWs at the baseline might be because they were either unaware or did not know how and where to get them. A similar challenge was reported in a previous study where FSWs could not get lubricants because they were scarce and due to insufficient information on how to get them.
Practice of anal sex among female sex workers
More than 20% of FSWs in both baseline and intervention groups had engaged in anal sex in the past 12 months. This risky behavior might be because the respondents in both studies (baseline and post-intervention) were willing to satisfy their customers and earn more money than insisting on vaginal sex with lower charges. Since they engage in the business to make ends meet, the interventions had little or no effects on the rate of anal sex; they must satisfy their clients in exchange for money or gifts. The prevalence of anal sex in this study is higher than what was previously reported in five states (Anambra, Cross River, Edo, Federal Capital Territory, Kano, and Lagos) in Nigeria, in which the prevalence of anal sex among FSWs was 5.2% in 2007 and 4.2% in 2010. This finding indicates that the rate of anal sex has been rising in the past decade, and it is evident that further preventive interventions are required. Such an increase in the prevalence of anal sex has also been reported in other parts of the world. For example, a study conducted at the Queensland University of Technology in 2007 revealed that the incidence of anal sex in the Queensland sex industry increased from 12.5% in 1991 to 16.0% in 2003. Although data from some studies in sub-Saharan Africa and some other countries show a low prevalence of anal sex among FSWs, some have documented a high prevalence of anal sex; for example, in a systematic review of behavioral risk factors of FSWs in sub-Saharan Africa by Scorgie et al. They found that some studies reported that less than 10% had ever practiced anal sex, whereas studies conducted in Kenya and South Africa reported that more than 40% had practiced anal sex. The review further supports our finding that the FSWs engaged in anal sex, because clients initiated it to attract a higher fee than vaginal sex. The sex workers believed that anal sex reduced the risk of being infected with HIV/STIs than vaginal sex.
In contrast, studies have shown that FSWs who practice anal sex are at a higher risk of acquiring HIV/STIs.,, Evidence has also shown that some clients violently force FSWs to have anal sex with them., Beyond the client satisfaction and money, it is also common for FSWs to believe that anal sex would reduce pregnancies and therefore may not object to it, especially if not using condoms. Some FSWs might engage in anal sex due to menstruation, under the influence of a substance, or for better pay. The motivation for anal sex among FSWs needs further studies.
Disease preventive measures by female sex workers
In this study, the baseline and intervention respondents were aware of any contraceptive methods though respondents after the interventions were more knowledgeable (P < 0.001). This finding indicates a greater awareness after the intervention programs. Generally, both baseline and intervention surveys showed that condoms are the most popular contraceptive method known among all respondents followed by oral contraceptives. In the past 12 months before the interviews, any contraceptive method was almost 100% among the intervention respondents against the suboptimal level (75.3%) among baseline respondents. This outcome is because the FSWs who participated in the intervention programs acquired a better understanding of the importance of contraceptives, had enough information regarding sexual risks, and had better access to the contraceptives. Poor use of contraceptives before the interventions may be a result of their nonavailability or inaccessibility. As previously documented, sex workers do not have access to adequate contraception in many regions.
The most widely used contraceptive method among participants in both studies was condoms. However, more than 90% of the participants in the post-intervention study had used condoms in the past 12 months, whereas 70% had used them at baseline. This finding aligns with the results of previous studies that condoms are the most widely used contraception method among sex workers., A study from the Netherlands has also shown that sex workers from Latin America and Eastern Europe use only condoms and no other contraceptive methods.
It is worth noting that the use of oral contraceptives dropped from 43% in the baseline study to 30.3% at post-intervention, whereas the use of other contraceptive methods such as implants and injectables increased significantly after the interventions. These findings can be attributed to the exposure of FSWs (during the intervention programs) to several contraceptive methods from which they could choose. Some of the FSWs might have opted for less stressful methods (no need for daily intake) such as implants and injections, which also have more prolonged effects. Besides, the intervention programs involved providing these contraceptives and referral to where they can be obtained from, meaning that the higher uptake of other contraceptive methods (other than oral contraceptives) might also be due to better access and availability.
At the time of the interview, almost all the participants in the post-intervention study were using any contraceptive method compared with the sub-optimal level in the baseline study. This result shows the significance of the intervention programs in creating awareness, availability, and improved access to the SHR services among FSWs. Previous studies have reported limited use of contraception among FSWs without SRH interventions, and consequently, they undergo abortions repeatedly.,, Several scholars have also noted the positive outcomes of interventions on the access and uptake of SRH services, such as contraceptives. For example, a study conducted in Zambia on integrating friendly SRH services for young FSWs found that the friendly manner in which health-care providers offer SRH services to the FSWs encouraged them to access services such as contraceptives and treatment for STIs and HIV. A similar intervention study involving FSWs in a multicountry implementation research project found that the use of contraception increased from 84.5% before interventions to 95.4% after the intervention, with an increase in the use of condoms from 55.3% to 67.7%.
This study has its limitations. One of the limitations is that the data obtained are self-reported, and some may give socially acceptable responses, which may not reflect the true situation. However, in this study involving baseline and intervention surveys, the clear differences between the two surveys show that the data obtained can be reliably accepted.
| Conclusion|| |
This study has documented the outcomes of two years’ grassroots interventions involving FSWs in Benue State, Nigeria. Since the interventions have been successful in improving the sexual behaviors of the FSWs, it is recommended that such interventions be extended to men who have sex with men, people who inject drugs, transgender people, and other key populations in Nigeria. This step will help extensively in the fight against HIV and STIs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The ethical research clearance was sought and obtained from the National Health Research Ethics Committee of Nigeria (NHREC) with approval number NHREC Protocol Number NHREC/01/01/2007–08/03/2019.
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[Table 1], [Table 2], [Table 3], [Table 4]