Prevalence of Sexual Assault and Use of Emergency Contraceptives Among Female Commercial Sex Workers in Dodoma city, Central Tanzania: A Cross-Sectional Study.

Female Commercial Sex Workers (FCSW) are in a constant risk of being abused by their customers or community. With the increased rate of unwanted pregnancies signify the problem in preventive measures and emergency contraception. This study aimed on assessing prevalence of sexual assault and use of emergency contraceptives among female commercial sex workers in Dodoma city, Tanzania. A descriptive cross-sectional study was conducted to 326 female commercial sex workers with a snow ball sampling technique in 10 administrative wards of Dodoma city where by selection of 10 wards from 41 total wards was performed systematically through excel.


Abstract
Background Female Commercial Sex Workers (FCSW) are in a constant risk of being abused by their customers or community. With the increased rate of unwanted pregnancies signify the problem in preventive measures and emergency contraception. This study aimed on assessing prevalence of sexual assault and use of emergency contraceptives among female commercial sex workers in Dodoma city, Tanzania.

Methods
A descriptive cross-sectional study was conducted to 326 female commercial sex workers with a snow ball sampling technique in 10 administrative wards of Dodoma city where by selection of 10 wards from 41 total wards was performed systematically through excel.

Conclusion
FCSW suffer a signi cant sexual assault which most of them are afraid to report these assaults basing on the nature of worker being illegal. Most of them heard about emergency contraceptives but few of them are consuming them in their protection against unwanted and unplanned pregnancy.

Background
Commercial sex referred to an act of exchanging sexual intercourse and other sexual pleasures with something valuable in return for several purposes including generating income 1 . Globally, female commercial sex workers (FCSW) differ from one place to another 2 . Commencementreasons into that business is still personal 1 but in developing countries, poverty 3 , lack of employment, civil war was mainly noted to be the courses 4 .
Worldwide there is a gargantuan number of FCSW and some are living with HIV 5 with a global prevalence of 11.8% up to 30%higherthan other women of reproductive 6 . They are alsopresupposed to be a source of HIV andSTI's transmission 7,8 due to unprotected consummation and having many couples 7,9 .A study performed in Australia revealedthe increased in burden of STI's which are bridged by involvement in commercial sex with 39% rise in chlamydia and 47% in gonorrhea infections with low HIV prevalence among FCSW which was 0.2% 9 . China has prevalence of 49% 8,10 with an estimated of 4 up to 10 million sex workers 11 . Brazil has also large number of commercial sex workers 12 but with minimal number of HIV infected FCSW 13 due to its maintained lower country-wise HIV prevalence 14  Apart from commercial sex work being attributed in escalation of HIV and other sexual transmitted infections 19 , it has also been associated with the great increase in unwanted pregnancies 20 . Most of these FCSW have children and some of them have families also 21 , they both in a need of structuring families despite being labeled bad 22 . Knowledge regarding pregnancy intention and preparedness lack to many FCSW 23 as most of them are unable to access health services 24 and hence predisposed to unwanted pregnancies 25 and give birth to children which lead to them continue working so that to feed families 16,21,26,27 . Nearly quarter of all FCSW in Sub-Saharan countries have one child 28 .
Maternal mortality and morbidities among these FCSW have been ignored for number of years and no any consideration has been laid on it 21 . Most FCSW deal with infection preventions and leave aside consideration about their reproductive health concerns 23 . 23.7% of women in Ethiopia with cervical cancer were noted to engage themselves in commercial sex workwhich showed that, they were predisposed 4 . Study done in India alsorevealedpredicament in counselling FCSW on how to breast-feed as they are constant at risk of being infected, hence most of them lack prenatal services as well as breast-feeding recommendation 24 . 81.6% of Indian commercial sex worker initiated breast-feeding 24 with no knowledge on mother to child transmission 23 . Community stamping towards FCSW is what made them lack important reproductive health serviceslike any other women of reproductive age 23 .
According to nature of work itself, leads into so many actions which put FCSW into danger 1 and these violation of some human rights 25 . Other commercial sex-workers face heightened sexual violence, victimization 8 and other social isolations 9 . In so many regions across the globe they receive high level of brutality from their customers, sexual riskand worse part of it, some cannot access health services 24 .
Study performed in Guatemala revealed that most of FCSW are in danger as they are vulnerable to poor health, gender based violence and sexual exploitation 2 . Canada Supreme Court laid a huge protection to these sex workers 23 while in Kenya they receive extreme violation of some of their common human rights 25 . Joint United Nation Program on HIV/AIDS launched a program in 2014 which aimed in promoting FCSW to have access to health services including family planning despite these violence 29 .
Tanzania also protects their human rights but local government prohibit that sex work 30 and the law of country criminalize the act of selling sexual activities 6 , being a criminal act made most of FCSW to hide their victimization, violence due to commercial sex and not even to seek medical help in a fear of being prosecuted 31 .
Contraception method which most of FCSW are aware of, is condom 17,19 . Consistent use of condom was reported in Australia 9 while in China most of these workers are in low social economic status and 62.5% up to 95% are immigrant, hence become unable to negotiate with their customers about condom use 8 . In United Kingdom, they commonly use condom with their customers but not regularly with their intimate partners and hence increase the risk of transmission sexually transmitted infections 22 . Kenya implement a policy and program for FCSW to promote condom use 29 to which 29% up to 74% adhere to it 28 . Tanzania reported inconsistent use of condom among FCSW as most put their prices regarding type of sexual pleasure a customer needs to receive including condom-less coitus 6 .
Little is known about FCSW in Tanzania which brought a motive for this study. Sex work is performed almost in all regions in Tanzania but mainly in the big cities. Assault has been noted to be performed to these FCSW in Tanzania as reported in several medias and these violence have been keep them in danger and lead into performing of this work incognito 32 . Most of these sex workers have been limited to access to several family planning services including access to contraception 19,21,22,25,28,29 so most of them tend to use condom as a method of infection prevention as well as contraceptive method. Very little information has been explored in Tanzania and it is still unknown if knowledge of emergence contraception has been delivered to these FCSW in Tanzania. The main purpose of this research was to assess prevalence of sexual assault and use of emergency contraceptives among FCSW who are mainly working in Dodoma City in central Tanzania.

Study design and Setting
A descriptive cross-sectional study was conducted between March and April 2019 in Dodoma City, Tanzania. The city is subdivided into 4 divisions (Urban, Hombolo, Kikombo and Zuzu Division) comprising of a total of 30 wards and 42 villages/streets. Dodoma Region lies in the eastern-central part of Tanzania and it is the capital city in the country. According to the 2012 national census, the region had a population of 2,083,588 33 .The most dominant ethnic group is Gogo but other ethnics exist too such as Sandawe, Rangi, Sukuma, Chagga. People of this area are involved in economic activities like business, livestock keeping, o ce work and farming 34 . Dodoma city was selected for this study because it is a fastgrowing city in Tanzania with high population of youths.

Study population
The study population wereFemale Commercial Sex Workers who were around during the time of study.

Inclusion criteria
Inclusion criteria were Female commercial sex workers who consented to participate in the study

Exclusion criteria
Female commercial workers who were serious sick and those with pronounced mental illnesses.

Sample size calculation
The sample size was obtained by using the Kish Leslie formula 35,36 .This study used an estimated prevalence of 50% as a standard to calculate the sample size.

Sampling technique
The sampling technique used in this study was a snow ball technique, where the rst respondent was found then she assisted in obtaining the next respondent, next respondent assisted to obtain the followed respondent until the required sample size was obtained. The identi ed possible respondent if consented was enrolled to the study but if she refused, she only assisted to obtain the next respondent. If she also refused to assist in obtaining the next respondent the previous respondent was consulted to assist in obtaining another possible respondent.

Data Collection Procedure
Street survey using interviewer administered semi-structured standardized questionnaire was used. The English version interview questions were translated into Swahili by three times back and forth translation with double check from linguists, to obtain data from the study participants and to ensure they understand the contents properly. The female commercial sex workers were asked for consent and it was made clear to them that they are free to make a choice to participate or not because there won't be any punishment for that.

Data Processing and Analysis
Page 6/17 The data collected through questionnaires was rst coded, and entered into SPSS version 25. Data cleaning was performed before analyzing the data's so as to identify the incorrect data, missing data during entering and duplicate data. Then data were subjected to simple descriptive statistical analysis. The model which was used for analysis was logistic regression which was used to determine the association between dependent and independent variable.

Ethical Consideration
The letter of permission for the conduction of this study was obtained from research and ethical committee of the University of Dodoma. Permission from the local authorities to collect data to the wards and streets was also obtained. The rights of the participant were well protected by obtaining informed consent in oral and written form. And con dentiality was assured among the respondent who agreed to participate in the study.

Socio-demographic characteristics
A total of 326 commercial sex workers were included in this study with a response rate of 85%. Majority of study respondents 58% were aged between 21 to 31years, 85.2% were not living with a male partner, 62.3% begin sexual intercourse at the age between 15 years to 20years, 88.1% had post primary education and 52.1% had homes (see Table 01).
Prevalence of sexual assault among female commercial sex workers More than a half 51.8% of the interviewed respondents had experienced sexual assault (see Fig. 01).

Use of emergency contraceptive
Majority of study respondents (64.4%) had never used emergency contraceptives (see Fig. 02).

Determinants of emergency contraceptive use among commercial sex workers
Socio-demographic characteristics which showed signi cant relationship with use of emergency contraceptives were ever being pregnant (p = 0.002), Ever used drug (p < 0.001), level of education (p = 0.009) and ever heard about emergency contraceptives (p < 0.001), see Table 02.

Discussion
Majority of study participant assessed were adolescents and adults as in the other study done in China focused into that population 11 . Study revealed early initiation of sexual activities for most of commercial sex workers with most of them being single mothers living with a family and the rest of majority being divorced, this array presence of commercial sex workers who have intimate partners or once before 7 .
Study area being a city with universities, make a place where even university student take part into this business as it was noted in other places where educated and skilled people go in for it 22 . Even though in this study plus other studies revealed that most participant of commercial sex work are those ended in junior and senior high school 5,7,25,29 .
Under this study, sexual assaults were put to be visible as majority of study participants communicate to be assaulted in performing this commercial sex in number of ways. The responses exhibit the torture and suffering these Tanzanian female commercial sex workers went through in their business regimen from their customers, intimate partners as well as community at large, this goes in line with so many published researches which depict hardship these commercial sex-workers pass through 1,13,25,37 . But at the same instance, other studies revealed number of reasons to which project these FCSW into suffering sexual assault which were not assessed in this study which is the status of immigration, majority of the assaulted commercial sex workers under the study done in China showed that is the state of not being inhabitant of a particular area 8,38 . Hence, the prevalence of sexual assault in Tanzania is very high which call for a serious attention as progression of these acts might further lead into violation of human rights, these assaults being the rst in East Africa followed by Kenya which is going behind other East Africa member countries 20 .
Tanzanian FCSW were noted to be far left behind as far as family planning knowledge is concerned. This has been due to the fact that performing these commercial sex works face moral and religious constraint in the community with a veneer of composure cracked a little to effectuate the act. This study divulges that most of FCSW had never use emergency contraceptive methods while doing their business, this has been eminent to be due to lack of knowledge regarding it and inattentiveness in their midst and much less consideration in their proper wellbeing 39 and inner ill-motives of inconsistence use of condoms 6 .
Prevalence of the use of emergence contraceptive in Tanzania were noted to be very small as majority of assessed individual delineated not to use these contraceptives and this propensity of many FCSW not being using emergency contraceptive has been reported in number of researches which impart the same as in the ndings of this study 20,37 . But in unison with that there a numbers of studies which showed that there are FCSW which are knowledgeable about emergence contraceptives and they have been adhering into it 19,25,37 and for that reason pose a challenge in delivering the same knowledge to the Tanzanian commercial sex workers at large with a challenge of it being illegal and proscribe work 31 .
Interdiction of commercial sex work in Tanzania 31 has hampered delivering of knowledge to these vulnerable groups regarding their health exceptionally concerning their reproductive health apropos of their work to expand their knowledge regarding emergency contraception. Findings of this study disclosed that those who ever heard about emergency contraception were ve times more likely to use them than those who had never heard about it. In harmony with this, another research let out the same ndings, most of the consumer of emergence contraception methods among FCSW were those who have access to health services and likely to receive education about it at some point 25 . Most of Tanzanian FCSW who heard about emergency contraception must be just by chance so far within the limit of our knowledge no any project is implemented to these FCSW regarding family planning methods, so most of them must had acquire these knowledge in their visitation to hospital with the concerns other than commercial sex work. Another uncovering from other studies indulged dearth of knowledge about emergency contraception but most of the FCSW still use other methods aside from condom and use those methods as back-up methods in case condom method failed 37 hence go averse with the ndings of this study.
Surprisingly, those who were noted to use drug of abuse were more likely to use emergency contraceptives more than those who are not abusing drugs. Most of commercial sex workers under this study were reported to be involved in abusing drugs and also another research done in Albuquerque showed that most are tempted and are at risk of starting abusing drugs but those who abusing it are nevertheless adhering to personal protections inclusive of emergency contraception 40 . Most of commercial sex workers are using drugs to conceal their immoral act toward society perception, but luckily most of those who are informed about emergence contraception they still use it 3 . In Tanzania, they are equiprobable to use them as they are the one who are mostly involved in the work more than those who are not abusing drugs and this has been conforming with the study performed in China which showed most of commercial sex workers are using drugs of abuse but still adhere to emergence contraception 11 . But also uncovering of this research has been denied by a study performed in Canada which manifested the escalation of drug addiction and predisposition to unwanted pregnancies with a surge risk of channeling HIV and other sexual transmitted infections 41 . Even though it is still ill-de ned on how Tanzanian FCSW acquire that knowledge about emergency contraception and another study reported the use of drugs to be low in Tanzania among FCSW 6 .
Education level among FCSW was also seen to affect the adherence to emergency contraception use in a paradoxical direction through which those who reached to the college were acclaimed to be less likely use emergence contraception than those with no formal education. This was attributed by nature of customers and methods of sexual activities as it has been espied in the study done in United Kingdom 22 also intention of receiving a lot money from customers was noted to be result of them not to use 6 .
Antithetical ndings also showed that education contributed a lot in the decision and readiness of these sex workers to use emergency contraceptive 1,21,42 .

Conclusion And Recommendation
Finally, female commercial sex workers in Tanzania suffer a signi cant sexual assault which most of them are afraid to report these assaults basing on the nature of worker being illegal and banned by the government. Most of them heard about emergency contraceptives but few of them are consuming them in their protection against unwanted and unplanned pregnancy. Obtained knowledge regarding emergence contraceptive is still unclear on how they acquire such a knowledge, further study needs to be done to access it. Nature of the work being illegal in Tanzania also number of interventions has to be implemented on how to stop this work so as to reduce number of sexual assaults, transmission of HIV and STI's, unwanted pregnancies as well.

Declarations
Competing Interest Authors rea rm that, there is no competing interest in both nancial and non-nancial.

Acknowledgement
Accomplishment of this work based much on our respondents, and we truly acknowledge them. Knowledge generated after thorough analysis does not necessarily re ect a personal respondent opinion or researcher's as well.

Funding
This study was sponsored by Higher learning Education Students Loans Board (HESLB) -Tanzania. The funding played a role in preparation of the study and data collection. Findings of this study was not in either way in uenced by HESLB.

Availability of data and materials
Data and materials are available to all and can be accessed from corresponding author via ellisteven.es@gmail.com or fabiola.moshi@gmail.com Author's contribution YS and EE participated in study plan, framework and data collection. FM added knowledge in data analysis and SK made a review of all the work. All authors participated in a manuscript preparation and    Figure 1 Prevalence of sexual assault among female commercial sex workers. Use of emergency contraceptives.