Introduction

The provision of sexually transmitted infections (STI) treatment and the promotion of condoms enhance preventive behaviour and reduce STI/HIV incidence among female sex workers, which in turn has the potential to reduce STI/HIV in the larger population.^1,2 Where people go for treatment when they have symptoms of an STI has major implications for disease control. It is also important to know what the women themselves expect and perceive as a priority with regard to sexual health services.

In Abidjan, Côte d'Ivoire, a clinic for female sex workers has been in operation since 1992.³ This clinic is a research centre, but offers also services to female sex workers, including free primary health care. For reasons of confidentiality, the clinic does not advertise itself. Strategies to inform the target population about the clinic include peer health education and outreach activities by the clinic personnel.

The objectives of this study were to describe health seeking behaviour of female sex workers in Abidjan, including their preferences and their actual choice of services.

Methods

A population based survey was conducted during September 1997 in Abidjan, Côte d'Ivoire. A representative and random sample of 500 female sex workers out of an estimated total number of 5000 was taken, using two stage sampling, with the probability of selection of work sites (clusters) proportional to their size. At each of the 100 selected work sites a random sample of five women was taken. Women who refused to participate or did not complete the interview were replaced by the next women on the random sampling list. Trained interviewers conducted face to face interviews at the work site, using a structured questionnaire.

After preliminary analysis of the population based survey, focus group discussions were held in August 1998, to further explore the results of the quantitative survey. Six discussion groups of 7–12 women were assembled according to nationality, and included two groups of women from Côte d'Ivoire, two from Ghana, and two from Nigeria.

Statistical analysis of the quantitative data was done using the intercooled stata 5.0 statistical package (Stata Corporation, TX, USA). For non-normally distributed quantitative data, median and percentiles 25 and 75 (P25–75) were used to describe the distribution. Kappa statistics were used to measure agreement between preferences and choice of services. The results of the focus group discussions were transcribed and summarised.

The study received approval from the institutional review boards (IRB) of the National AIDS Control Program, Abidjan, Côte d'Ivoire and the Institute of Tropical Medicine, Antwerp, Belgium and was determined to be exempt by the IRB of the Centers for Disease Control and Prevention, Atlanta, USA.

Results

Of a total of 540 invited women, 510 agreed to participate in the study, and a completed questionnaire was obtained from 500 women. The median age was 26 years (P25–P75: 22–32). Thirty nine per cent of the women interviewed were from Ghana, 38% from Côte d'Ivoire, and 14% from Nigeria. Their median duration of sex work was 2 years (P25–P75: 8–48 months).

Thirty per cent of the women reported malaria as their most important health problem, 25% abdominal pain, and only 2% STI. Thirty per cent of all women reported a history of STI symptoms ever. Women were asked where they had sought treatment during their last STI and malaria episode. The answers are shown in table 1 and were very similar when comparing STI and malaria treatment. The main reason for satisfaction was the perceived efficacy of the treatment, reported by 82%. The confidential clinic was also appreciated because of the free treatment and the friendly reception, reported by, respectively, 37% and 10% of the women who attended this clinic. The agreement between reported preferred and used actual services was weak (kappa 0.16). Of the women who reported preferring public health services, private health services, and the special clinic, 39%, 41%, and 33% respectively sought treatment in the informal sector (market, street vendors, or friends) for their most recent STI episode.

These results were further explored during focus group discussions. Financial barriers were indicated by all groups to be the main reason for not visiting a public health centre when experiencing health problems. Unfriendly reception was reported by the Ghanaian and the Nigerian women. The latter preferred the private clinics in their home country because they were larger and better equipped than the private clinics in Abidjan. The reason why some women avoided the confidential clinic, despite the free treatment and the perceived quality of services, was also explored. The women complained about the blood tests and the long waiting times, related to research activities.

Discussion

Understanding how people make decisions about their health can help to identify obstacles to early diagnosis and effective treatment of STI and to the design of appropriate interventions. Our results indicate a large gap between their stated preference, and what sex workers in Abidjan actually do when they have a health problem. Financial barriers were reported as the most important limiting factor for not going to the health structures they preferred. In Côte d'Ivoire, government services are theoretically at low cost, but patients' expenses can be considerable because of transport costs and costly prescriptions.⁴ Other studies indicate some other factors which may has a role in poor health seeking behaviour, including stigmatisation, sex, long waiting time, and distance to treatment.^5–7

Surprisingly few women used the free health services at the confidential clinic. Many of the study participants had recently arrived in Abidjan and did not know about the existence of the clinic. In order to increase the coverage of the clinic, outreach programmes should be sustained and expanded.

What can be learned from this study in terms of setting up services for high risk women in similar settings? Specialised health services such as the confidential clinic in Abidjan may offer better opportunities for targeted educational sessions and health promotion. However, such services should make themselves known to the target population by outreach activities, and some sex workers still prefer to attend services that cater for the general population. For this reason, public and private healthcare facilities should be made more accessible for sex workers, and their services should be upgraded to better respond to the sexual health needs of female sex workers. Offering a range of options for sexual health care to high risk women is probably the best way to control STI and HIV in this population.