Elsevier

Contraception

Volume 94, Issue 1, July 2016, Pages 34-39
Contraception

Original research article
Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers,☆☆

https://doi.org/10.1016/j.contraception.2016.03.004Get rights and content

Abstract

Objective

Female sex workers (FSWs) need access to contraceptive services, yet programs often focus on HIV prevention and less on the broader sexual and reproductive health needs of FSWs. We aimed to identify barriers to accessing contraceptive services among FSWs and preferences for contraceptive service delivery options among FSWs and health care providers (HCPs) in order to inform a service delivery intervention to enhance access to and use of contraceptives for FSWs in Kenya.

Study design

Twenty focus group discussions were conducted with FSWs and HCPs in central Kenya.

Results

Three barriers were identified that limited the ability of FSWs to access contraceptive services: (1) an unsupportive clinic infrastructure, which consisted of obstructive factors such as long wait times, fees, inconvenient operating hours and perceived compulsory HIV testing; (2) discriminatory provider–client interactions, where participants believed negative and differential treatment from female and male staff members impacted FSWs' willingness to seek medical services; and (3) negative partner influences, including both nonpaying and paying partners. Drop-in centers followed by peer educators and health care facilities were identified as preferred service delivery options.

Conclusions

FSWs may not be able to regularly access contraceptive services until interpersonal (male partners) and structural (facilities and providers) barriers are addressed. Alternative delivery options, such as drop-in centers coupled with peer educators, may be an approach worth evaluating.

Implications statement

An unsupportive clinic infrastructure, discriminatory provider–client interactions and negative partner influences are barriers to FSWs accessing the contraception services they need. Alternative service delivery options, such integrating contraceptive service delivery at drop-in centers designed for FSWs and information delivery through peer educators, might provide improved access and better service quality to FSWs seeking contraception.

Introduction

Public health programs have focused on the prevention of HIV and other sexually transmitted infections (STIs) among female sex workers (FSWs) for decades [1], [2]. Yet, other sexual and reproductive health (SRH) needs of FSWs, such as access to contraceptive services, have received less consideration. A recent review of public health programs targeting FSWs in Africa revealed that few programs have addressed SRH needs [3].

FSWs need access to comprehensive SRH prevention measures because factors that place them at increased risk for HIV and other STIs — multiple sexual partners and inconsistent condom use — also place them at risk for unintended pregnancies and abortion. Previous research has shown that FSWs often want to prevent future pregnancies, but they face challenges initiating and sustaining use of more effective contraceptive methods; most rely on condoms alone to prevent HIV and pregnancy [4], [5]. Women's access to and use of contraceptives often depends on factors such as community norms, male partner preferences and product availability, in addition to personal preferences, which can be shaped by misconceptions, costs and previous experiences with side effects [6], [7], [8].

In Kenya, despite the efforts of various public health programs targeting FSWs, unintended pregnancy and unmet contraceptive need remain high. Sutherland et al. [4] reported that FSWs in Kenya frequently experienced unintended pregnancies, often resulting in induced abortions because of concerns that pregnancy would lead to a loss of clients, violence from a regular partner and additional financial burden. Here we describe the barriers to accessing contraceptive services and preferences for contraceptive service delivery options among FSWs and health care providers (HCPs) in central Kenya.

Section snippets

Methods

From January to May 2012, we conducted 20 focus group discussions (FGDs) — 16 with FSWs and 4 with HCPs who had provided or who were planning to provide services to FSWs — in three towns in the Rift Valley region in Central Kenya: Naivasha, Gilgil and Nanyuki. Naivasha and Gilgil are located in Nakuru County, the fourth largest county in Kenya. Nanyuki is an urban center in a nearby county, Laikipia [9] (Naivasha and Gilgil were treated as one site because of their proximity). Public health

Study population

A total of 172 FSWs participated in 16 FGDs (Table 1). FSWs' ages ranged from 18 to 49 years (median = 27). Most of the FSWs (94%) had been previously pregnant, and 29% reported having had an abortion. Among FSWs who were not pregnant (n = 165), almost all (97%) reported that they were currently using contraceptives; 89% reported using male condoms, 30% reported using an injectable contraceptive and 23% reported using oral contraceptive pills (Table 2).

Twenty-three HCPs participated in four FGDs (

Discussion

Our findings suggest that FSWs want contraceptive service delivery options that adapt to their specific needs and welcome them as clients. Substantial barriers exist, however, at both the structural (facilities and providers) and interpersonal (male partners) levels, making it difficult for some FSWs to regularly access contraceptives services in these communities. At the structural level, FSWs described an unsupportive clinic environment: clinics' operations did not accommodate their needs and

Acknowledgements

We are grateful to the individuals who participated in the study and shared their perspectives and experiences with us. We also appreciate the numerous study staff who helped implement the study.

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Cited by (0)

Conflicts of interest: None.

☆☆

Funding: The United States Agency for International Development funded this study through the Preventive Technologies Agreement No. GHO-A-00-09-00016-00. The funder did not have any role in design of the study; collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the article for publication.

1

Duke University, Durham, NC, United States.

2

U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States.

3

Current affiliation: Government Accountability Office, Boston, MA, United States.

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