Original research articleContraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers☆,☆☆
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)
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Conflicts of interest: None.
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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.
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Duke University, Durham, NC, United States.
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U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States.
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Current affiliation: Government Accountability Office, Boston, MA, United States.