STI Care Seeking Behavior and Associated Factors Among Female

Medicin ity e & un H m e a Shewangizaw et al., J Community Med Health m l t o h

C E

d Journal of Community Medicine & Educ 2019, 9:3

n o

J Health Education ISSN: 2161-0711

Research Article Open Access

STI Care Seeking Behavior and Associated Factors among Female Sex Working in Licensed Drinking Establishments’ of Adama Town Oromia Regional State, Ethiopia 2017, by Employing Health Belief Model Shewangizaw H1*, Aderajew N2 and Alemi K2 1Department of Midwifery, College of Health Science, Mizan-tepi University, Mizan-Teferi, Ethiopia 2Department of Population and Family Health, Institute of Health Science, Jimma University, Jimma, Ethiopia *Corresponding author: Dr. Shewangizaw H, Department of Midwifery, College of Health Science, Mizan-tepi University, Mizan-Teferi, Ethiopia, Tel: +251912814203; E- mail:[email protected] Received date: February 23, 2019; Accepted date: May 21, 2019; Published date: May 28, 2019 Copyright: © 2019 Shewangizaw H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Female sex workers constitute one of the high risk groups for STIs including HIV acquisition and transmission. In many societies Female sex workers face stigmatization, marginalization and discrimination, including in the health-care sector due to this fact great majority of female sex workers tend to self-diagnose and seek over-the-counter medication from pharmacies or use traditional home remedies for STIs treatment rather than visit health institution. Hence, assessing the factors that hinder or facilitate STIs care seeking behavior in this population group is imperative.

Methods: A cross-sectional study was conducted from March 01/2017 to 30/2017 among 423 female sex workers. Interviewer administered standardized tool that were pre-tested in Mojo town was used to collect data. Backward conditional multivariate logistic regression model was employed to identify factors associated with STIs care seeking behavior.

Result: Among the respondents 55.9% have utilized STIs care services. Three constructs of the health belief model namely perceive susceptibility (AOR=2.33, CI: 1.13, 4.80), perceive severity (AOR=3.25, CI: 1.65, 6.41) and cue to action (AOR=2.82, CI: 1.46, 5.43) were significantly associated with STIs care seeking behavior. Furthermore, knowledge of sexual transmitted infection (AOR=5.36, CI: 3.08, 9.34), having symptoms of sexual transmitted infection (AOR=3.95, CI: 2.18, 7.16), having non-paying sexual partner (AOR=1.95, CI: 1.09, 3.48) and duration of sex work (AOR=0.5, CI: 0.29, 0.86) were among the modifying variables that show significant association.

Conclusions: The results of this research reveals that 3 components of the HBM perceptions namely perceived susceptibility and perceived severity and cue to action were significantly associated with STIs care seeking behavior. Among the modifying variables having sexual transmitted infection symptoms, knowledge of sexual transmitted infection, duration of sex work and having non-paying sexual partners were found to be strong predictors of STIs care seeking behavior among the female sex workers.

Keywords: Female sex workers; Perceptions; STI care seeking monitoring of the ‘weekly Venereal Diseases (VD) Control Program’. behavior; Adama; Ethiopia Nevertheless, this periodic STI and CD examination service was discontinued in the 1980s following VD Control Program integration Background with general health services [3]. In 1996 Female sex workers were recognized as population at risk of HIV by Federal Democratic Female sex workers have been recognized in Ethiopia since olden Republic of Ethiopia Ministry of Health. FHAPCO in its 2010 report times, although there are no documented data as to when and where on the implementation of the UN Declaration on Commitment on female sex workers first appeared in the country. Few sources link the HIV/AIDS as a matter of these declaration, female sex workers’ access beginnings of sex business with the movement of kings, nobles and to HIV prevention, and care services has increased dramatically with a warlords, the development of cities and the advancement of trading network of drop-in centers all over the country providing advice, [1]. In Ethiopia, it is illegal to operate a brothel establishment or condoms and income generating activities [4]. procure sex workers for commercial purpose, but the sale of sex by women is not prohibited by law [2]. The number of women entering in sex business is increasing especially in the sub-Saharan African countries escalated by problems During the 1970s, female sex workers working in drinking associated with urbanization, pressure from poverty, food and political establishments (hotels, bars and restaurants) and waitresses were insecurity and civil unrest. Female sex workers constitute one of the periodically examined for Sexually Transmitted Infections (STI) and high risk groups for STIs and HIV/AIDS acquisition and transmission other communicable diseases at government health institution, as a [5]. In many societies FSW face stigmatization, marginalization and

J Community Med Health Educ, an open access journal Volume 9 • Issue 3 • 1000656 ISSN: 2161-0711 Citation: Shewangizaw H, Aderajew N, Alemi K (2019) STI Care Seeking Behavior and Associated Factors among Female Sex Working in Licensed Drinking Establishments’ of Adama Town Oromia Regional State, Ethiopia 2017, by Employing Health Belief Model. J Community Med Health Educ 9: 656.

Page 2 of 8 discrimination, including in the health-care sector, which may delay Methods treatment seeking [6]. Due to their high HIV prevalence, their increased ability to transmit HIV when co-infected with other STIs, Study area and design and to the large population groups they reach through their sexual network, sex workers have long been targeted as the ‘core group’ most A cross-sectional study was conducted from March 01/2017 to at risk of acquiring STI and HIV [7]. 30/2017 in Adama town, Oromia National Regional State found at the distance of 99 km from Addis Ababa, based on the 2007 Census The continuing stigma and discrimination surrounding women who conducted by the Central Statistical Agency of Ethiopia, the city has a engage in sex work make the provision of comprehensive STI/HIV total population of 220,212, of whom 108,872 are men and 111,340 prevention, care, treatment and support for this vulnerable population women. The town has a high concentration of bars, hotels, and night challenging [8]. Only one third of FSWs in Sub-Saharan Africa had clubs where most female sex workers work. The majority of these reported to receive adequate STI/HIV prevention interventions and facilities are located along the main Addis-Djibouti road, Adama- very few number of female sex workers had access to STI/HIV Asella road, and Kebele [15]. In the town, there are an estimated 6,000 prevention, treatment, care and support [9]. Female sex workers are female sex workers and 95 licensed drinking establishments [18,19]. venerable to a number of negative health consequences. They engage in Adama hosts several schools and colleges with a high number of youth. high risk sexual behaviors, which might predispose them to sexually There are also some street girls and female school youth who practice transmitted infections, rape, violence and adverse reproductive commercial sex. Moreover, numerous industries and plantations outcome. Despite these facts, they are in a poor position to utilize attract many migrant workers from different part of the country. health service particularly sexual health care service when compared to the general population due to perception of health and illness, financial constraints and unfavorable conditions in the health care setup [10]. Source population Furthermore, poor socio-economic conditions and working under All female sex workers working in licensed drinking establishments hardship in order to financially support one’s family contributes to found in Adama town. inadequate STI care service utilization among this group [11]. Female sex workers usually perceive themselves as inferior than Study population other population and tend to lead their life in social isolation and this Female sex workers who were recruited from licensed drinking perceived disadvantaged position in the society has impacted the poor establishments and residing in Adama town by the time of the data health care service utilization by the female sex workers [12]. Studies collection process were considered to be the study population. have evidenced that social and emotional factors inhibit female sex workers from utilizing STI care service [13]. There is a firm association between behavior to seek care timely and the perceived outcome of Sampling procedure and data collection service utilization. The promptness of seeking care service will be due A quota sampling approach was employed to recruit the to the female sex workers own evaluation of their health, illness and respondents. (As per WHO sampling hard to reach population risk behavior [14,15]. recommendations and Ethiopian behavioral surveillance survey Due to delay in treatment seeking female sex workers suffer from [20,21]. Preliminary exploration was undertaken to figure out the the complications or late effects of STI infections, such as pelvic minimum number of female sex worker working in the drinking inflammatory disease (60% of cases of pelvic inflammatory diseases establishments for this list of all licensed drinking establishment was caused by an STI) the long-term sequelae include ectopic pregnancy, required to undergo the preliminary exploration and this registration chronic pelvic pain and tubal infertility. The increased risk of pelvic list was obtained from Adama Town cultural and tourism office. The inflammatory disease-induced infertility is a health problem that is registration list contained information such as establishment’s address particularly important as female sex worker try to leave out of the sex (kebeles and phone number), and types of the drinking establishments. work and change into other personal roles, such as trying to have a Identification of the name of each establishment achieved by family [16]. Even though there is limited data on the incidence and contacting and consulting with community health agent of each prevalence of STIs in Ethiopia, the prevalence of STIs is generally respective kebele offices and voluntary female sex workers working in believed to be high similar to that of other developing countries. Due FGAE confidential clinic. Based on the registration list the to low level of knowledge regarding STI care service utilization large establishments where verified whether they are engaged in the business proportion of client seek care from traditional healers, pharmacy or not furthermore the minimum number of female sex workers pharmacists, drug vendors shops and marketplaces, where the care is working in each establishment was identified in the preliminary not the standard practice [17]. exploration. According to the preliminary exploration there were 120 drinking establishment in the town that are engaged in the business As to the investigators knowledge, this is the first study conducted and the minimum number of female sex workers working in the among female sex workers on STI care seeking behavior. Previously establishments was found to be four. For the purpose of assigning published studies that applied HBM were conducted among groups equal “quota” to each drinking establishment the total sample size was other than female sex workers. The existing studies that have been divided by four which is the minimum number of female sex worker in undertaken in this group mainly assess HIV screening uptake, the establishment and it gives 106 establishments. From the total of 120 knowledge about STIs and condom utilization etc. So, this study establishments 14 establishments were excluded using lottery method. addressed STI seeking behavior of female sex workers ’ and the Finally, four female sex workers from each establishment were predicting factors. recruited in order to achieve the total sample size required. As shown in Figure 1. Ten voluntary female sex workers that have already been working with the FGAE confidential clinic were hired as data collectors.

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Ethical consideration After approval of the proposal, ethical clearance and formal letter was obtained from Population and Family Health department and research ethics committee of Jimma University. Informed consent was obtained from each participant after explaining the purpose of the study. The anonymity of data was kept at all stage of data processing.

Result

Socio-demographic characteristics

Figure 1: Schematic presentation of sampling technique, Adama Among 423 female sex workers selected in the study, 390 were town Oromia regional state, Ethiopia, March, 2017 (N= 390). responded to the interviewer administered structured questionnaires making response rate of 92.2%. The mean age of the respondents was 24.05 with SD of 4.18. The minimum and the maximum age of respondents were 18 and 40 respectively. The overall socio- Study variables and measurement demographic characteristics of the study participants are summarized The outcome variable was STI care seeking behavior and by Table 1. respondents were asked if they had visited health facility for STIs concern (for treatment, receiving condom, screening, and consultation No Variables Response Frequency Percent etc.) in the past 12 month. Independent variables were Age, educational status, duration of sex work, marital status, religion , past ≥24 226 57.9 history of STIs symptoms, having non- paying client, type of paying 25-34 157 40.3 client, use condom with non-paying client, use condom with paying 1 Age client, age at first sexual intercourse, sexual behaviors, STIs knowledge, ≤35 7 1.8 perceived susceptibility, perceived severity, perceived benefits and Total 390 100 perceived barriers. The health belief model constructs were measured by asking respondents a set of questions. The responses for these items Unable to read and write 52 13.3 ranged from 1 (strongly disagree) to 5 (strongly agree). The result was dichotomized in to two “High” and ‘Low” based on the mean score of Read and write 47 12.1 the construct. Knowledge of STI was measured by asking respondents Grade 1-8 158 47 8 question. The responses for the first items was 1 (“Yes”) 0 (“No”) and 2 Educational status the rest 2 items asks to list STI symptoms in male and female. The Grade 10-12 86 22.1 correct response for yes no question had a score of one and if the Above grade 12 22 5.6 respondent correctly mentions at least one symptoms of STI in female would have a score of 1 and if the respondent correctly mention at least Total 390 100 one symptoms of STI in male would have a score of 1. Then scored points were dichotomized in to Good knowledge and poor knowledge Married 58 14.9 depending on the mean score of knowledge of STI. 3 Marital status Single 332 85.1

Data analysis Total 390 100 Data was checked for completeness, edited, cleaned, coded and Orthodox Christian 169 43.3 entered in to Epi-Data version 3.1 and then exported to SPSS version Muslim 101 25.9 20 for analysis. Univariate analysis was employed, first frequencies of each items was observed then the descriptive (measures of central Protestant Christian 73 18.7 tendencies and variations) was examined. Chi-square analysis was 4 Religion used to identify any significant association with STI care service Catholic Christian 45 11.5 utilization and selected variables. A final backward conditional Other 2 0.5 multivariate logistic regression was performed to identify what factors best explain STI care seeking behavior. P-value of 0.05 or lower was Total 390 100 taken to declare that the association is statistically significant. Strength Yes 185 47.4 of association of the variables was described using odds ratio at 95% Any family to confidence level. The result was presented as frequency table, graph 5 No 205 52.6 support and discussed with finding. Finally, possible recommendations were made based on the finding. Total 390 100 1-3 Years 226 57.9 6 Duration of sex work >3 164 42.1

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Total 390 100 Common STI symptoms in the past 12 month Female sex workers were asked if they had history of common Table 1: Socio demographic characteristics of female sex workers symptoms of STIs syndromes in the past 12 months, the majority 276 working in licensed drinking establishments of Adama town Oromia (70.8%) had history one or more of the symptoms of STIs. The regional state, Ethiopia, March, 2017 (N=390. common STIs symptom reported by the female sex workers in the past 12 month prior to the study is summarized by Table 2.

No Symptoms Frequency Percent

1 Genital discharge 120 30.8

2 Burning pain during urination 78 20

3 Genital ulcers/sore 72 18.5

4 Swellings In groin area 60 15.4

*Multiple responses were possible; percentages calculated according to the female sex worker involved in each category and do not add up to 100 percent.

Table 2: Self-reported symptoms of STIs among female sex workers working in licensed drinking establishments of Adama town Oromia regional state, Ethiopia, March, 2017 (N=390).

Female sex workers’ STIs knowledge government hospital, 12 (8.5%) pharmacy, the rest 10 (7%) sought treatment from traditional healing as shown in Figure 2. Regarding Knowledge of STI, 367 (94.1%) of the respondents claimed to have ever heard about sexually transmitted infection (STIs) Among those who had sought care 78% of the respondents had among them 179 (45.9%) of the respondent mentioned that STI can be visited health care within 1 month of symptom recognized. Those prevented, 162 (45.9%) mentioned that STI can be cured and 139 FSWs who hadn’t sought care for their genital symptoms mentioned (35.6%) mentioned that STI can be asymptomatic. One hundred sixty different barriers in utilizing the services, negative staff attitude, lack of two (41.5%) of respondent correctly responded to the statement which privacy, long waiting time and high cost of treatment were the most inquires “people can protect them self’s by using condom correctly and frequently mentioned barriers in utilizing the service. consistently” and 152 (39%) correctly responded to the statement which inquires “having one of STIs other than HIV can increase risk of acquisition of HIV”. Female sex workers were also asked about the common sign and symptoms of STI both in women and men, 225 (57.7%) of the respondent mention at least one sign and symptom of STI in women the common mentioned symptoms were abdominal pain, genital discharge, foul smelling discharge, pain on urination, genital ulcers/ sores, swellings in groin area. Concerning symptoms of STI in men 265 (67.9%) of respondent mention at least one symptom of STI in men the common mentioned symptom in men were genital discharge, burning pain during urination, genital ulcers/sores and swellings in groin area. The overall comprehensive knowledge score out of eight questions were calculated by summing the score of each item and one hundred Figure 2: Distribution the place where female sex workers sought eighty seven (47.9%) of the respondents had good knowledge of STI care for their genital symptoms, Adama town Oromia regional state, and the rest two hundred three (52.1%) of respondent had poor Ethiopia, March, 2017 (N=390). knowledge of STI.

Female sex workers’ STI care seeking behavior Measurements of theoretical constructs Among the respondents 218 (55.9%) have utilized STI care services for different reason in the past 12 month prior to the study. Among With respect to measurement of the theoretical constructs users of STI care services 80 (36.7%) have utilized the service of respondents score high perceived barrier followed by perceived benefit treatment purpose, 69 (31.6%) for screening purpose the rest visited which is 3.77 and 3.28, respectively. The mean score of the rest of the for consultation service and condom receiving 36 (16.5%) and 32 theoretical constructs are depicted by Table 3. (14.7%) respectively. As shown in the above table respondents perceive a fear high score Out of 276 respondents who had history of STI symptoms, only 142 for all health belief model perception. When the theoretical construct (51.4%) sought some form of treatment for their condition. When dichotomized in to high and low depending on the mean score, asked for the place where they sought treatment, 61 (43.0%) sought majority of the respondent had high level of HBM perception as shown treatment in NGO clinics, 43(30%) private clinic, 16 (11.3%) in Figure 3.

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perceive susceptibility, perceive severity, perceive benefit and cue to action were the variables with p value less than 0.25 and become candidate variables for the final multivariate logistic regression analysis. The rest variables namely, marital status, any family to support, condom use with non-paying client, condom use with paying client and perceived barrier show no association with STIs care service utilization (P value ≥ 0.25).

Predictors of STIs care seeking behavior in multivariate logistic regression In the final backward conditional multivariate logistic regression analysis all the variables with P-value<0.25 in bivariate logistic Figure 3: The score of HBM perceptions of female sex workers regression namely educational status, duration of sex work, having working in licensed drinking establishments of Adama town non- paying sexual partner, type of paying client in past 2 week, having Oromia regional state, Ethiopia, March, 2017 (N= 390). history of STI symptoms in the past 12 month and knowledge of STI, perceive susceptibility, perceive severity, perceive benefit and cue to action were entered. Thus, the final model demonstrates that Perceive No utilized STI care Utilized STI care susceptibility (P-value=0.022), perceive severity (P-value=0.001), cue service service No Theoretical to action (P-value=0.002), knowledge (P-value<0.001), having STI constructs Std. symptoms (P-value<0.001), having non-paying sexual partner (P- Mean Std. Deviation Mean Deviation value=0.023)and duration of sex work (P-value=0.013) as the most

Perceive significant factors that were significantly associated with STI care 1 3.2 0.86 3.82 0.75 susceptibility seeking behavior among female sex workers. Variables such as educational status, type of paying client in past 2 week, perceived 2 Perceive severity 3.14 0.9 3.88 0.78 barrier and perceive benefit failed to show significant association with

3 Perceive benefit 3.28 0.91 4.02 0.74 STI care seeking behavior among female sex workers. Female sex workers with high score of perceived susceptibility for 4 Perceived barrier 3.77 1.03 3.78 1.05 STI were 2.3 times more likely had STI care seeking behavior than 5 Cue to action 3.06 0.9 3.84 0.8 those with low score of perceived susceptibility[AOR 2.330, 95% CI (1.130,4.802)], female sex workers with high score of perceived severity Table 3: Mean and standard deviation of theoretical constructs scores for STI were 3.25 times more likely had STI care seeking behavior than of female sex workers working in licensed drinking establishments of those with low score of perceived severity [AOR 3.257 95% CI Adama town Oromia regional state, Ethiopia, March, 2017 (N=390). (1.655,6.411)], female sex workers with high score of cue to action 2.8 times more had STI care seeking behavior than those with low score of cue to action [AOR 2.821, 95% CI 2.821 (1.464,5.439)]. Regarding the Predictors of STIs care seeking behavior in bivariate logistic modifying variables, female sex workers with high score of knowledge regression were 5.36 times more likely had STI care seeking behavior than those In the bivariate logistic regression all potential explanatory variables with low score of knowledge [AOR 5.364, 95% CI (3.080,9.340)], namely educational status, marital status, any family to support, female sex workers who had history of STI symptoms were 3.9 times duration of sex work, having non- paying sexual partner, condom use more likely had STI care seeking behavior than those without with non-paying client, condom use with non-paying client, type of symptoms[AOR 3.953, 95% CI (2.180,7.167)], female sex workers who paying client in past two week, having history of STI symptom in the had non-paying sexual partners were 1.9 times more likely had STI past 12 month and knowledge of STI, perceive susceptibility, perceive care seeking behavior than those without non-paying sexual partner severity, perceive benefit, perceived barrier and cue to action were [AOR 1.956, 95% CI (1.097, 3.485)] and female sex workers staying in entered in the bivariate logistic regression discretely to detect the effect the business for more than 3 years were 0.5 times less likely had STI of individual explanatory variable on the likelihood of STI care service care seeking behavior than those working 1-3 years [AOR 0.500, 95% utilization. Among the variables examined in binary logistic regression CI (0.290,0.862)]. The final multivariate logistic regression model that ten variables such as educational status, duration of sex work, having depict variables which significantly predict STI care seeking behavior non- paying sexual partner, type of paying client in past 2 week, having among female sex workers are summarized by Table 4. history of STI symptoms in the past 12 month and knowledge of STI,

Variables Not Utilized n (%) Utilized n (%) COR AOR at 95% CI

Perceive susceptibility

Low perceive susceptibility 88 (77.9%) 25 (22.1%)

High perceive susceptibility 84 (30.3%) 193 (69.7%) 8.088 2.330(1.130,4.802)*

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Perceive severity

Low perceive severity 99(75.6%) 32 (24.4%)

High perceive severity 73 (28.2%) 186 (71.8%) 7.883 3.257 (1.655,6.411)*

Cue to action

Low cue to action 88 (75.2%) 29 (24.8%)

High cue to action 84 (30.8%) 189 (69.2%) 2.821 2.821 (1.464,5.439)**

Knowledge of STI

Poor knowledge 138 (68.0%) 65 (32.0%)

Good knowledge 34 (18.2%) 153 (81.8%) 9.554 5.364 (3.080,9.340)**

Had STI symptoms

Had no STI symptom 72 (63.2%) 42 (36.8%)

Had STI symptom 100 (36.2%) 176 (63.8%) 3.017 3.953 (2.180,7.167)**

Non-paying sexual partner

No 65 (53.7%) 56 (46.3%)

Yes 107 (39.8%) 162 (60.2%) 1.757 1.956 (1.097,3.485)*

Duration of sex work

1-3 Years 88 (38.9%) 138 (61.1%)

3> Years 84 (51.2%) 80 (48.8%) 0.607 0.500 (0.290,0.862)*

*means P value <0.05 and **means P value <0.01; Note: The table shows only significant variables after controlling for educational status, type of paying client in the past 2 week, perceived benefit and perceived barrier; For all the variables the first category was taken as a reference group.

Table 4: Multivariate logistic regression of socio-demographic and theoretical variable of the study subject with dependent variable, Adama town Oromia regional state, Ethiopia, March, 2017 (N=390).

Discussion The most frequently mentioned barrier in utilizing STI care service were negative staff attitude, lack of privacy, long waiting time and high It appears from the study that 55.9% of female sex workers stated cost of treatment. Similar hurdles were identified as barriers to care that they personally subject themselves to health institution for STI seeking behavior among female sex workers in other studies carried concern (for treatment, consultation, for receiving condom etc). This out in Kigali, Rwanda and Loas [28,29]. In this study majority of the proportion is similar with the study undertaken in Davangere city, female sex workers with STI symptoms sought STI care service Central Karnataka 51.2% [22,23] and Nairobi, Kenya 49.3% [24] and predominantly from the private sector and NGO clinics, seldom from lower than study undertaken in Ogun State, Nigeria in which majority the public sector. These finding is consistent with other studies of the female sex workers 80.9% had used STI care service [25]. This conducted regarding care seeking for STI symptoms among sex may be due to the non-existence of female sex worker friendly service workers in Pakistani [30] and Parades, India [31]. This similarity may in public facilities in the study area. Among female sex workers with be due to the fact that public health facility found in those countries previous STI symptoms 48.6% of the study subjects did not seek care my not provide favorable institutional environment that can suit for their genital symptoms. This is consistent with study undertaken in MARPs specifically female sex workers. Kano, Nigeria 46% and India 48.3% [26,27] suggesting that majority of them with STI symptoms did not seek care for their genital symptoms. Regarding condom utilization more than 59.7% had used a condom However, among those that sought care, 68.9% did so at greater than consistently with paying clients during the past 12 month prior to the one month after self-recognizing the symptoms. Delay in seeking STI study. This finding is congruent with the study conducted in Adama on care service among female sex workers were also evidenced by other work-related violence and inconsistent condom use [32] and studies conducted in Uganda 73.6% and Angola 66.7% [10,11]. This Bangladesh [33]. Majority of the Female sex workers (69%) had non- delay in utilizing STI care service may be due to the perceived paying sexual partners among them 60.8% used condom consistently, stigmatization and discrimination by the female sex workers in those when having sex with their non-paying sexual partners during the past countries. Lack of or a delay in utilizing STI care service result in 12 month prior to the study. This implies female sex workers use missed opportunities to manage STI, as STI care providers can directly condom in the same pattern when having sex with their paying and deliver interventions such as treatment, counseling and condoms non-paying client. Disparity in condom usage pattern between paying directly to those who have STIs. and non-paying client has been evidenced by other studies conducted

Page 7 of 8 in Blantyre, Bahirdar and Adama [34-36]. The more likely explanation literature the study fails to compare and contrast the finding of HBM for this discrepancy in finding might be attributable to the roll of NGO theoretical dimensions. run confidential clinic found in Adama town. This may possibly have significant impact on the attitude of female sex workers towards Conclusion condom utilization with both paying and non-paying client. Sixty percent of the female sex workers visit health institution for Genital symptoms (genital discharge 30.8%, burning pain during STI apprehension most of them were predisposed by self-recognized urination 20% genital ulcers/sore 18.5% and swelling in groin area STI symptoms. Among those with history of STIs symptoms majority 15.4%) were common among the female sex workers. This finding is sought care from NGO clinics and private health facilities. There were comparable with other study undertaken in Rwanda and Pakistan several barriers mentioned by those female sex workers who hadn’t [29,30], suggesting high prevalence of STI among female sex workers sought treatment for their genital symptoms. The barriers were related and consequently this signify a high potential for STI and HIV to both structural and individual factors comprising long waiting time transmission among this group. in the clinic, high cost of treatment, judgmental attitudes of healthcare Concerning HBM perceptions, the study revealed that majority of providers and lack of privacy. the female sex workers had high score of perceived susceptibility for The behavioral schematic design (HBM) was employed in this STI (71%), perceived severity for STI (66.4%), perceived benefit of STI study. The results found that 3 of the Health Belief Model perceptions care service utilization (72.6%), perceived barrier for STI care service perceived susceptibility, perceived severity and cue to action were utilization (76.4%) and cue to STI care service utilization (70%). Other significantly associated with STI care seeking behavior. High perceived studies that applied HBM in explaining HIV screening behavior susceptibility, High perceived severity and High cue to action were among female sex workers, reveals the same finding in which majority positively associated with STI care seeking behavior. Other variables of female sex workers scored high for all of the HBM perceptions like having symptoms of STIs, good knowledge of STI, having non- [37,38]. paying sexual partners were positively associated with STI care seeking This study considered a range of potential predictors including behavior. Duration of sex work greater than 3 years was negatively socio-demographic, sexual behavior, knowledge, perceived susceptibly, associated with STIs care seeking behavior. perceived severity, perceived benefit, perceived barrier and cue to STI care service utilization. Seven variables (perceived susceptibility, Author’s Contributions perceived severity, cue to action, knowledge, having symptoms, having non-paying sexual partner and staying in the business for more than 3 Hailemariam Shewangizaw designed the study, trained data years were strong predictors of STI care seeking behavior. In this study collectors and managed data collection. Nigusse Aderajew, having good knowledge of STI were positively associated with STI care Hailemariam Shewangizaw, Kebed Alemi conducted the statistical seeking behavior among female sex workers (P value<0.001) similar analysis and drafted the manuscript and provided input into data study conducted in among female sex workers in Peru and Senegal analysis and overall study progress. All authors reviewed, edited and substantiated this finding [36,37]. approved the final manuscript. The likelihood of STI care service utilization were positively Acknowledgements associated with having history of one or more of the STIs symptoms (P value<0.001). Other studies conducted in Ohio, America, Bangladesh, The author’s deepest gratitude and sincere appreciation goes to India sustained this finding [38]. Which means asymptomatic female Adama FGAE confidential clinic staffs that were cooperative in sex worker tends to visit health institutions less often than those who offering imperative information. Author’s would like also to thank all had already noticed the symptoms. This might implies that female sex voluntary female sex workers that were enthusiastically take part in the workers usually contemplate themselves as healthier as long as they data collection process. I want to acknowledge the 4th Annual don’t recognize the symptoms. The finding of this study indicated that Congress and Medicare Expo on Primary Healthcare and Nursing for female sex workers staying in the business for more than 3 years were providing opportunity to present the paper. less likely to utilize STI care service than those with 1-3 year experience. This result is in agreement with the study conducted in References loas [28]. This may be for the fact that staying in the business for a long period makes them dispirited and feel less responsiveness for their 1. Pankhurst R (2017)The history of prostitution in Ethiopia. J Ethiop Stud health concern. 12: 159-178. 2. Article 634 (1994) The criminal code of the federal democratic republic of Generally, the majority of respondent in this study perceived a high Ethiopia. Proclamation. level of perception for all HBM constructs. Perceive susceptibility 3. International FH (2002) Mapping and census of female sex workers in perceive severity and cue to action were the constructs that family health international (FHI )-Ethiopia Addis Ababa city significantly associated with STI care seeking behavior. Female sex administration health bureau (AACAHB). workers with high score of perceived susceptibility, perceived severity 4. Overs C (2014) Sex workers, empowerment and poverty alleviation in and cue to action were more likely had STI care seeking behavior than Ethiopia. those with low score. This study is unique because it uses HBM to 5. Rojanapithayakorn W (2006) The 100% condom use programme in Asia. depict a STI care seeking behavior. 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J Community Med Health Educ, an open access journal Volume 9 • Issue 3 • 1000656 ISSN: 2161-0711