Female sex workers’ characteristics
We recruited 40 study participants. The sample had a mixture of brothel and street based FSWs. Twenty-eight had less than 20 years. Thirty-four FSWs had completed primary school education as their highest level of education.
Table 1
Socio-demographic characteristics of female sex workers (N=40).
Characteristics
|
N
|
%
|
Age (N=40)
|
|
|
Less than 20 years
|
28
|
70
|
20-30 years
|
10
|
25
|
More than 30 years
|
2
|
5
|
Education
|
|
|
Primary
|
34
|
85
|
Secondary
|
6
|
15
|
Tertiary
|
0
|
0
|
Place of birth
|
|
|
Rural
|
29
|
72
|
Urban
|
11
|
27
|
Other characteristics
|
|
|
Consistent condom use
|
21
|
52
|
STIs
|
33
|
82
|
FSWs desired to have few children
|
36
|
90
|
Fear of side effects of contraceptives
|
32
|
80
|
Unmet contraceptive needs
|
28
|
70
|
Identification of the components of the toolkit
Different themes emerged among the study participants:
Misinformation and misconceptions on contraceptives
The study participants highlighted the needs to clarify some misconceptions on contraceptives when teaching FSWs on safer sex behaviour and contraceptives. Twenty-one FSWs narrated that indeed there are myths and misconceptions among FSWs and the general population.
Many of us believe that once women start taking the contraceptives, it is very unlikely that she will conceive again [Age range 20-25]
Woman always have watery vaginal discharges while on contraceptives. Most of our clients dislike them. [Age range 20-25]
Contraceptives reduce libido both in males and females. “Explain in details. Asked the data collector” Males also are affected by the contraceptives because they always have sex with their partners who are on contraceptives. [Age range 25-30]
Some women believe that after unprotected sexual intercourse douching or urination works as contraception method [Age range 15-20]
Inclusion of STI and HIV prevention measures
Study participants emphasised that the training should also focus on prevention measures against STI and HIV.
You know these women, they sleep with so many men and most of the time they don’t use condoms. If you don’t teach them how to protect themselves properly, all of them will be infected with STIs including HIV. Therefore it is very important to gain knowledge on how to protect ourselves [Age range 30-35]
Despite using condoms people are still getting infected with HIV and STIs. Is it possible to find out the reasons why it is happening like that? [Age range 30-35]
The use of PREP and PEP should be well explained to FSWs. Only very few FSWs are aware of them. [Age range20-25]
Effectiveness of contraceptives
Female sex workers narrated their experience while and after using the contraceptives. They have negative perceptions resulting from the side effects. Some proposed to make good and better contraceptives because the current ones affect their business negatively. During our intervention there was explanation of contraceptives and different alternatives.
Contraceptives prevent pregnancy… this is good. But they cause bleeding, and loss of libido. We are FSWs, how can you approach a client when you know that you are bleeding? [Age range 25-30]
Taking the pills on daily basis is not helpful. You may forget! But if you find us pills which can work for long time, we can appreciate. Injections make us bleed continuously. [Age range 30-35]
Female sex workers’ empowerment
Female sex workers explained the needs for their empowerment. Without alternative reliable sources of income FSWs have only one option of survival, sex work.
It’s not our wish to be FSWs. This is the result of poverty. Find us the source of income then we will forget the sex work. Teach us other ways to generate money, we are tired of sex work. [Age range 20-25]
Please link us to organisations which can assist us. We want to do business. We can pay back after sometimes. You can’t became rich as result of sex work. [Age range 25-30]
Right to justice
Female sex workers expressed the need to have a legal framework allowing them the to operate freely. Currently whenever they complain about brutality and many forms of harassment from several groups’ perpetrators, they are rarely heard by the law enforcers.
In many circumstances the police officers don’t listen to us, even when the issues presented to them are genuine. We are not protected. Please talk to the police to listen and understand our concerns. We are like any other citizens of this country. [Age range 30-35]
In other country FSWs are much protected. Here we are beaten anyhow, raped, and abused. Please protect us. [Age range 25-30]
Access to contraceptives and other health care services
Female sex workers expressed their concerns about the availability of contraceptives and other health care services (ART, PEP, PrEP, screening and counselling services). This problem is very common in health centres.
It’s good that FSWs will be conversant with contraceptives but although the Government provides the contraceptives for free of charge, most of the time they are out of stock in many health centres [Age range 25-30]
Many organisations assist FSWs with condoms, lubricants. They come to test us while in the field. We will appreciate if health care providers bring the contraceptives to our homes or in the field. (Age range 25-30)
Evaluation of the toolkit
Qualitative method was used to evaluate the toolkit and the intervention. Feedback from FSWs, healthcare providers (Nurses and clinicians) on the relevance, content, structure, applicability and feasibility was sought.
Relevance of the toolkit
Regarding the overall evaluation of the toolkit, the majority (70%) reported it was relevant, satisfactory and useful. It was perceived to have potential to positively impact behaviour change among FSWs.
I am satisfied with the content of the toolkit. I managed to learn a lot during the training, the facilitator explained the content of the toolkit very well. Issues related to myths and misconceptions were clearly addressed. We have an idea of the type of contraceptive suitable for us. We will start using dual method as soon as possible. We acquired adequate information to prevent STI and unintended pregnancy. [Age range 20-25]
This document has reminded me what we have to do as nurses and clinicians. We must look after them (FSWs). We should not be judgemental. [Clinician. Age range 25-30]
This document is very useful and relevant to all of us: FSWs, health workers, and the community. If we don’t protect FSWs against diseases, they will get sick and during sex work they may meet our husbands, children and/or our relatives. Think about what will happen if your husband gets HIV from FSWs, you will be infected as well. Let us use the toolkit for our protection. [Nurse. Age range 30-35]
I think the best way to be heard by authorities, we must organise in groups or join other groups then we present our issues as a group. Otherwise we will not have the right to justice. This discussion was very important because now we have some ideas on issues related to right to justice. [FGD 1]
Organization and presentation of the toolkit
Sixty per cent (60%) of the FSWs reported that the toolkit is very well organized and presented. Fifty-five per cent of the clinicians said although the toolkit organisation was good some slides were very long. There was need for some modification.
The document is well presented. But it can be better if it is produced in the form of book (hard copy) so that people without computers (power point facility) can access and use it as well [FGD 1]
The document is well organized and presented. The facilitator explained using simple language to accommodate everybody. It will be better if it is translated in different vernacular languages spoken here in Malawi [FGD 1]
The document is well presented and organized. All the challenges encountered during sex work were included and possible solutions were provided. [FGD 3]
Applicability of the toolkit and the intervention
The training was made easy by this toolkit, we managed to learn a lot. We can now easily transfer the knowledge gained to other fellow female sex workers and friends. [FGD 2]
We will be very confident to explain or teach FSWs on contraceptives and safe sex behaviour using the same toolkit. We will appreciate if you share with us the slides so that we can use them elsewhere during teaching sessions. [FGD 3]
This intervention was very important. It brought FSWs closer to the health care providers. We will not be judgemental and FSWs will not be afraid to approach us whenever there is a need. I have shared already the toolkit with my fellow health care providers. [FGD 4]
Feasibility of the intervention
The intervention was conveniently done. Due to this intervention, there is now closeness between FSWs and health care providers. This rarely happens. [Age range 25-30]
I liked the learning atmosphere. FSWs were very open. They expressed their views and they were eager to learn. The facilitator was very accommodative. [Clinician. Age range 30-35]