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Female condom; Female commercial sex worker; Utilization

The female condom (FC) is a new device invented in the 1980s as an alternative strategy aimed to ensure female controlled safe sex practice, to empower women and keep them from sexual and reproductive health risks [1-3]. In addition to protect female sex workers it is also aimed to protect their male clients. However, it is not be fully accessible, acceptable and utilized by the women in the reproductive age at all level [4]. It offers women double protection- it has a potential for reducing unprotected sex, protects pregnancy and sexually transmitted infections including Human Immune Virus (HIV) infection [2, 3, 5]. Nevertheless, accessibility and low promotion by governments lead to dominated usage of male condom than FC [4]. Even, in spite of promotion, its utilization is low for different factors influencing women’s sexual decisions making, sexual behavior, social and cultural forces. The availability of female condom made the difficult sexual decisions easy by enabling them to take an active role in protecting themselves in the relationship and safer sax [6]. Female condom is the safest method to reduce new HIV exposure among young women, reduce risk of unwanted pregnancy and infection prevention for vulnerable women like female commercial sex workers [5]. It is made available on a market for women who are not able purchase and for those who are not able to access it because of limited distribution [7]. The study shows that there was successful introduction of female condom and women showed initial motivation, but continued acceptance and utilization was the problem [8]. This would be affected by gender inequality in sexual relationships. It is mentioned that women do not to take active role in sexual decisions, negotiation- limiting their decision making power to initiate FC use [6]. Studies indicates low utilization of FC regardless of promotion by most of the countries in the world [7]. For instance the study conducted in South Africa shows low utilization of female condom, in spite of good knowledge.

The prevalence of HIV infection is twice higher in women than men. This shows that new infection and vulnerability is high among women and shows extra efforts to control the risk, including proper promotion and distribution of FC utilization especially for female commercial sex workers to control the infection.

The study found that high cost of kit in women with limited income, lack of education, cultural barriers, financial constraints, inability to negotiate safer sex and the belief that condoms inhibit sexual pleasure and distribution methods, legal and policy, and structural barriers were affecting its utilization [4, 8]. Province, age group of participants, positive attitudes, peer influences and norms, limited awareness, absence of promotion, and low visibility in markets [5, 7] were also found to be barriers of female condom utilization.

The study done in Ethiopia identified that area of residence, knowledge about RH information and attitude towards FC were found to be significant predictors for willingness to use FC. Unavailability and unacceptance by the community were also affecting its utilization [2].

In Ethiopia every year many young new women engaged in the sex work as business irrespective of having good knowledge about HIV/ AIDS and other sexually transmitted disease prevention and safer sex practices. This study is intended to assess the level of FC utilization and associated factors among female commercial sex workers in Sebeta town.

Study Area and Period

This study was conducted in Sebeta town, special zone of Oromia Regional State, 25 km away from Addis Ababa city, capital of Ethiopia. It is bounded by Addis Ababa in the South, Sebeta Hawas woreda in the East, West and North direction. The town has total population of 352504, of whom, 146818 (41.65%) are females and 205686 (58.35%) are males (CSA). According to information taken from social affairs and health office the town, during data collection period, there were around 392 female commercial sex workers in the town. The town has ten kebeles, 30 hotels and bars with 11 night clubs. The main business in the town include, industrial parks with different factories, hotels, bars, local drinking establishment, private higher educational institution, pension and massage house with other small to big super markets (Source Sebeta town social affairs office and health Office June, 2019)

Study Period: The study was conducted from July/2019 to August /2019.

Study design: A cross sectional study design supplemented with qualitative method was conducted.

Source population: All female sex workers in Sebeta town were the source population.

Study population: Study population was all female commercial sex workers and fulfilling the inclusion criteria.

Inclusion and exclusion criteria

Inclusion criteria: Female commercial sex workers who were above 18 year’s old and agreed to participate in the study.

Exclusion criteria: Female commercial sex workers who were severely ill and unable to respond to the interview were excluded from the study.

Sample size determination: For quantitative study, all female commercial sex workers found in the town were included in the study. For qualitative study, some information rich commercial female sex workers who were members of RH or HIV/AIDS club were selected purposively for in-depth interview.

Data Collection tool and procedure

Quantitative data were collected using pretested structured questionnaire which was developed after reviewing of similar studies. The data were collected by eight trained peer educators after taking verbal consent from the study participants. In-depth interview guide was used to collect qualitative data by investigator. During each interview sound recording and note taking was done.

Study variables

Dependent variable

• Female condom utilization

Independent variables

• Includes socio-demographic characteristics (age, place of work, income, primary occupation, ethnicity, religion, educational status), Client factors: money paid for sex, constant customer, client need, Exposure to RH service, Being involved in RH clubs., Availability female condom, Cost of female condom, Willing to use female condom and Perceived being at-risk.

Operational definition

Current use of female condom: Female who use FC at last three months of sexual for dual protection.

Utilization of female condom: Female commercial sex worker who ever used the FC to any sexual intercourse to HIV/AIDS and unwanted pregnancy prevention.

Exposure to RH service: participate who received any information related to safe sex and STI prevention by trainer or peer educators.

Client factors: any negotiation, or refused factors of male client to use FC during sex business.

Data quality control and assurance

The questionnaires were first prepared in English language and were translated into Amharic and Afan Oromo language for data collection purpose and then back to English for reporting of the result. The data collectors and supervisor were trained for two days on issue related to the objectives of the study, data collection procedure and ethical principles. The completeness of the collected data was checked on daily basis by supervisor and investigator.

In order to ensure quality of data, developed structured questionnaires were pretested on 5% of study population in similar setting with study area (Burayu town) and necessary modifications and corrections were made before the actual data collection. Study participants were told clearly about the objectives and advantage of the study, confidentiality of the collected data. Collected data were checked continuously on daily basis for completeness, accuracy and consistency and corrective action was taken.

Data Management and Analysis

Quantitative data were entered in to Epi-enfo version 4.2 then exported, cleaned, and analyzed using SPSS version 20. Summary statistic of variables was presented using frequency tables. Bivariate and multivariate logistic regression analysis was done. Accordingly, variables with p-value of less than 0.25 on bivariate analysis were transported to multivariate logistic regression analysis to determine the association between female condom utilization and explanatory variables. Model fitness was checked using Hosmer and Leme show goodness of fit-test. Finally, a variable with P-value ≤ 0.05 was considered as having statistical association with female condom utilization. Crude and adjusted Odds ratio as well as 95% confidence interval was constructed along with the corresponding P-value.

The audio recorded data were transcribed and translated from local language to English. Manual coding and thematic were done and narrative was used to report after direct verbatim quoting was done for qualitative part. Lastly, the result of quantitative and qualitative study was triangulated to address the objective of the study.

Ethical Considerations

Ethical clearance was secured and official letter of permissions were obtained from department of graduate committee of Madda Walabu University, Goba Referral Hospital. Then, permission letter was obtained from Sebeta town Health office. A verbal consent was obtained after participants are informed about the objective of the study and participation was voluntary. Confidentiality of participants maintained during reporting and analysis of the data

Socio-demographic characteristics of study participants

From the total of (392) female commercial sex workers in the town 370 of them participated on the study making a response rate of 94.4%. The age of the respondent’s ranges from 18 to 35 years and the mean age was 23.49 years with (SD) ± 3.604. Of the total respondents nearly two third of the study participants 244 (65.9%) were in the age group of 18–24 years. Forty percent (148) of the participants have reported that their monthly income is between 2500-5000 ETB. Regarding work place two-third 241 (65.1%) of them work in hotels followed by local drinking establishments 85 (23%). More than half of the FCSWs 236 (63.8%) were Orthodox Christian followed by 59 (15.9%), 57 (15.4%) Muslim and protestant respectively. Majority of the FCSWs, 230 (62.2 %) were single and followed by 77 (20.8%) divorced (Table 1).

Table 1: Socio-demographic characteristics of study participants in Sebeta town, special zone of Oromia region, enteral Ethiopia August; 2019.

Sexual and reproductive characteristics of study participants

Two hundred thirty nine (64.6%) of respondents were heard about Female condom. peer education was the major source of information. Hundred forty five (39.8%) of them were members of sexual and reproductive health clubs and of which 60.8% used sexual and reproductive health services provided in the club (Table 2).

Table 2: Awareness and perception in FC among study participants in Sebeta town, of special zone of Oromia region, central Ethiopia August; 2019.

Based on the finding of in-depth interview, all (seven) of the participants had informed or heard about female condom, and six of them were ever used the FC since, they are a peer educator groups participate in such peer educator training and access at training but they mention that the regular availability of FC is very limited. The study participants also described female condom promotion is not seen well.

From the interviewed respondent who served in hotel said, “Condom is my life savior. without Condom really sex bussines is impossible because there is great risk of exposure to disease… so, female condom accesability is crucial as that of Male in pharmacy. Even most Females don’t know this tools… every person should contribute for availability of tools, health provision supports in promotion and how to utilize Female condom.”

Lack of knowledge about female condom cause disagreements between the female sex worker and their male customers. For example one respondent stated that "due to lack of promotion about female condom, one of my clients insulted me and tried to hit me while I suggested to use Female condom by asking me what is that, I never heard and seen such a kind of things to be used as condom.”

There is also misunderstanding about female condom usage. Some thinks it is a tool used only for commercial sex workers. One of the participant mentioned that “FC is considered as a tools made and used only for FCSW… but it’s for all females and for our male clients and for dual protection during sexual intercourse, so every person should support and work in all community to increase acceptance and promote this tool as a Male condom…if possible training of key population in utilization and access of female condom is my recommendation.”

Individuals who received training know the advantage and when to use it. Those who know the how it works were also discussing with their peers and their customers. One of the respondent who took a training stated the following “I received a training on how to use this condom in Hawasa and Shashemane for similar purpose; I mean sex business and it was equally used as Male condom. I had used it and was comfortable with it, because penile erection is not must to use it, it has dual protection and I am ready to use always, if available. Additionaly

I have discussed with my peers on how to promote this condom and how to negotiate with our male clients in using it and many female sex workers have changed their attitude and accepted and ready to use ...”

All study participants during in-depth interview clearly stated the problem of accessibility of the female condom regularly as that of male condom and they feel happy if accessible and plan to use always. Some of them also mentioned that they got a device in the hotel and from the non-governmental organizations, but not regularly and not sufficient as demanded.

Factors associated with female condom utilization

After adjusting for the effect of confounders in multivariate logistic regression analysis, monthly income of the respondents (AOR= 2.86, 95% CI= (1.17, 4.93), educational level (AOR= 3.39, 95% CI= (1.17, 9.79) and being a member of RH club (AOR= 0.25, 95% CI= (0.11, 0.57) were found to have significant association with female condom utilization (Table 3).

Table 3: Factors associated with female condom utilization among commercial female sex workers in Sebeta town, special zone of Oromia region, in central Ethiopia, August; 2019.

This study aimed to assess the level of female condom utilization and associated factors among female commercial sex workers in Sebeta town, Ethiopia. Accordingly, about 16.5% female commercial sex workers were ever used female condom and 4.6% were current users. From those whoever used FC 12(19.7%), 31(50.8%) and 18 (29.5%) of them used once, two to ten times and more than ten times respectively. This is higher when compared with the result of the study done in the united states in which only 2.7% had ever used female condom. The possible reason for the difference in utilization of female condom could be due to time gaps between the studies. Relatively, study participants targeted promotion of tools by some nongovernmental organization and increased availability of female condom currently may increase its utilization.

Other reason may be, study participants difference, in which the current study was conducted on female commercial sex workers who are most at risk population for HIV/AIDS so that mainly targeted for prevention and control strategies with all new approach of HIV/AIDS prevention and focused area as they are key and priority population. Other reason might be in the study participants use condom is risk saving since they are engaged in commercial sex work which has high risk of HIV infection.

The qualitative data results found that all of the respondents heard about female condom. The majority of them were ever used it but, not regularly, attributed to unavailability of the condom at their nearby pharmacy, poor knowledge and poor promotion of female condom as that of male.

The study indicated that female commercial sex workers whose monthly income lies between 5000 to 7500 Ethiopian birr were nearly three times more likely to use female condom when compared with those earning less than 2500birr. Because of having many customers, females having high income are at high risk of contracting HIV/AIDS and others STI. This may force them to search for prevention methods that will help them to minimize the risk, which in turn will expose and enhance them to use female condom. The other possible explanation is, female sex workers that have better income may be able to purchase the condom than their counterparts. This is supported by the study conducted in Botswana that showed economic and financial barriers hinder the utilization of female condom.

This study also found that educational status and female condom utilization has positive relationship. As educational status of female commercial sex workers increased, the possibility of exposure to different HIV/AIDS prevention strategies as well as considering themselves as being at risk of HIV infection may increase. This may further improve the utilization of better HIV prevention strategies like female condom which provide vital role for female to actively involve and negotiate for safe sex during sexual intercourse with their clients.

In the current study, being a member of reproductive health club was found to have significant association with the female condom utilization. Female commercial sex workers who participated in reproductive health club were about four times more likely to use female condom than others. This may be due to the fact that being a member of reproductive club expose to a variety of information on safe sex and to a range of prevention modalities that will help prevent sexually transmitted diseases along with their advantages and disadvantages. This further enables female commercial sex workers to practice recently advocated HIV/AIDS and other sexually transmitted infection barrier methods like female condom. This is supported by the study done in Ethiopia (2) and Ghana (5) which revealed that reproductive health information has positive relation with female condom utilization.

Strength of the study

• To the best of our knowledge this is the first study in Ethiopia and no other similar studies in Africa and so can be used as a baseline for further studies.

• The study was also supported by qualitative method.

Limitation of the study

• Absence of similar studies in the area and on the same population limited discussion in comparison with other studies

• It may be difficult to generalize for the whole womens for its conducted on female commercial sex worker only.

Majority of the respondents were never used female condom. Unavailability of the device in the market/hotel, lack of knowledge on how to use it, clients did unwillingness, fear of affecting their business were a major reasons for not using it. Among those whoever used it, lack of continuous supply was also hindering them from using it regularly. Peers and health care workers were the main source of information for those who heard about female condom. Better income, better educational status and being a member of reproductive health club were positively affecting female condom utilization among the respondents.

Reproductive health departiments shall promote the use and ensure accessiblity of the FC to all female commercial sex worker in the hotels, nearby pharmacy and health institutions of the town. Education for women on utilization of female condom among female commercial sex workers and involving them in local reproductive health club will increase utilization.

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