title: Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa.
abstract: BACKGROUND
  Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities.
  
  
  METHODS
  A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Šidák correction.
  
  
  RESULTS
  Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics.
  
  
  CONCLUSIONS
  The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.
authors.affiliation: International Centre for Reproductive Health, Ghent University, Ghent, Belgium. yves.lafort@ugent.be.
authors.forename: Yves
authors.identifier: http://orcid.org/0000-0003-1380-2064
authors.initials: Y
authors.lastname: Lafort
authors.affiliation: MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
authors.forename: Ross
authors.initials: R
authors.lastname: Greener
authors.affiliation: Ashodaya Samithi, Mysore, India.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Roy
authors.affiliation: MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
authors.forename: Letitia
authors.initials: L
authors.lastname: Greener
authors.affiliation: International Centre for Reproductive Health-Kenya, Mombasa, Kenya.
authors.forename: Wilkister
authors.initials: W
authors.lastname: Ombidi
authors.affiliation: International Centre for Reproductive Health-Mozambique, Maputo, Mozambique.
authors.forename: Faustino
authors.initials: F
authors.lastname: Lessitala
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Jolene
authors.initials: J
authors.lastname: Skordis-Worrall
authors.affiliation: MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
authors.forename: Mags
authors.initials: M
authors.lastname: Beksinska
authors.affiliation: International Centre for Reproductive Health, Ghent University, Ghent, Belgium.|International Centre for Reproductive Health-Kenya, Mombasa, Kenya.|University of Nairobi, Nairobi, Kenya.
authors.forename: Peter
authors.initials: P
authors.lastname: Gichangi
authors.affiliation: University of Manitoba, Winnipeg, Canada.
authors.forename: Sushena
authors.initials: S
authors.lastname: Reza-Paul
authors.affiliation: MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
authors.forename: Jenni A
authors.initials: JA
authors.lastname: Smit
authors.affiliation: International Centre for Reproductive Health, Ghent University, Ghent, Belgium.|Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Matthew
authors.initials: M
authors.lastname: Chersich
authors.affiliation: International Centre for Reproductive Health, Ghent University, Ghent, Belgium.|The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa.|Center for Statistics, Hasselt University, Diepenbeek, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: Delva
mesh_terms: D000328:Adult; D003267:Contraception; D003430:Cross-Sectional Studies; D005260:Female; D005382:Financing, Personal; D006801:Humans; D007194:India; D007630:Kenya; D009073:Mozambique; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D034121:Reproductive Health Services / Q000706:statistics & numerical data*; D060386:Sex Workers / Q000706:statistics & numerical data*; D012725:Sexual Behavior; D012747:Sexual Partners; D013019:South Africa; D055815:Young Adult
keywords: Care seeking behaviour; Female sex workers; India; Sexual and reproductive health; Sub-Saharan Africa