'Health is wealth and wealth is health' - perceptions of health and ill-health among female sex workers in Savannakhet, Laos.

0.11 MB·English

by  Phrasisombath, Ketkesone

(cid:2)ORIGINAL ARTICLE
‘Health is wealth and wealth is
health’ (cid:2) perceptions of health and
ill-health among female sex workers
in Savannakhet, Laos
Ketkesone Phrasisombath1,2*, Sarah Thomsen2,
Vanphanom Sychareun1,2 and Elisabeth Faxelid2
1DepartmentofPostgraduateStudiesandResearch,UniversityofHealthSciences,Vientiane,Laos;
2Division ofGlobal Health (IHCAR),Department ofPublic Health Sciences,Karolinska Institutet,
Stockholm,Sweden
Background: Female sexworkers (FSWs) arevulnerableto sexually transmitted infections (STIs) and other
types of health problems and they also encounter socio-economic difficulties. Efforts to develop effective
healthinterventionprogramsforFSWshavebeenhamperedbyalackofinformationonwhyFSWsdonot
seekordelayseekingtreatmentforSTIs.Tofurtherunderstandtheirreasons,ourstudyappliedaqualitative
approach toexploreperceptions of healthandill-health among FSWs in Savannakhetprovince in Laos.
Methods: Fifteen in-depth interviews were conducted with FSWs in Savannakhet province. Latent content
analysiswasusedforanalysis.
Results: Sex workers’definitions of health andwealth are intertwined. Thus, good health was described as
stronglyrelatedtowealth,andwealthwasneededinordertobehealthy.Thisisexplainedintwosub-themes:
healthisnecessary forworkandincome andill-health creates socialand economic vulnerability.
Conclusions:Femalesexworkers’beliefsandperceptionsabouthealthandill-healthweredominatedbytheir
economic need,whichin turnwasinfluencedbyexpectationsand demands fromtheir families.
Keywords: perception;health;ill-health;femalesexworker;Laos
Received:29 June 2012; Revised:9 November 2012; Accepted:5 December 2012; Published:2 January 2013
Laos, with a population of 5.6 million, is a low- people, and social relations have become more diverse,
incomecountryinSoutheastAsia.Eightypercent especially among young people (3).
of the population live in rural areas. The literacy Despite economic development, Lao traditional cul-
rate for the population aged 15 years and above is 73%, ture and norms remain conservative. Sexuality is a
with fewer women (63%) compared to men (83%) being sensitive issue and sexual relations outside marriage are
literate(1).Seventy-onepercentofthepopulationliveon strongly discouraged for women. Conversely, pre- and
lessthan2US$adayand23%liveonlessthan1US$a extramaritalsexiswidelyacceptedformen,whosesexual
day(2).Duetoeconomicreformsinrecentdecades,Laos needs are perceived as normal and natural (4). A study
has experienced economic expansion, business transac- from Laos found that policy makers and healthcare
tions, and a blooming of the tourist industry and providers expressed negative attitudes towards young
transportation. However, these changes have also peoples’sexualityandrefusedtoofferemergencycontra-
brought domestic and cross-border migration, which ceptive pills because of the perception that it would
has increased social inequalities between people in rural encourage sexual relationships among young people (5).
and urban areas. Problems related to poverty have also Young women in Laos, especially in rural areas, have
arisenduetothisexpansion.Market-orientedgrowthand limited knowledge about sexuality and reproductive
urbanizationhaveinfluencedthelifestyleofordinaryLao health (4, 6). Gender inequality persists, and when
Sourcesofsupport:HealthSystemsResearchProgram,TheSwedishInternationalDevelopmentCooperationAgency,SwedenandLaos.
GlobHealthAction2013.#2013KetkesonePhrasisombathetal.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution- 1
Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,distribution,andreproductioninany
medium,providedtheoriginalworkisproperlycited. Citation:GlobHealthAction2013,6:19080-http://dx.doi.org/10.3402/gha.v6i0.19080
(pagenumbernotforcitationpurpose)
KetkesonePhrasisombathetal.
familiesarestressedfinancially,girlsareoftenkeptoutof suitable health interventions for them. In this study, we
school. Consequently, women have fewer opportunities exploreperceptionsofhealthandill-healthamongFSWs
for employment and are financially vulnerable, forcing in Savannakhet province, Laos. This study is part of
some women to engage in commercial sex as a mean of larger projectonperceptionsandcare-seeking behaviour
survival (7). aswellasbarriersrelatedtoSTIservicesamongFSWsin
Commercial sex, although a visible phenomenon in Laos.
Laos,isillegal.Giventhetraditional‘monogamysociety’
in Laos, female sex workers (FSWs) are perceived Materials and methods
negatively and stigmatized, especially among healthcare
providers (8). In Laos, FSWs prefer to be called service Studyarea
women. There are two types of FSWs in Laos: street- ThestudywasbasedinSavannakhetprovince,whichhas
basedFSWsandvenue-basedFSWs.Venue-basedFSWs thehighestprevalenceofSTIandHIVinfectionreported
are women who are officially employed as hostesses to among FSWs in Laos (9). Savannakhet province com-
workinentertainmentplaces(e.g.beerbars‘drinkshops’, prises 15 districts with one provincial and 14 district
karaoke bars, nightclubs, guesthouses, and restaurants) hospitals. The province has 132,301 households with
toprovideservicestoclientsintheformofconversation, 826,000 inhabitants, of which women represent 51% (1).
serving beer and snacks, but also selling sex (9). Venue- The literacy rate of the population aged 15 and above is
based FSWs provide sexual services in guesthouses or 68%. About 77% of the population lives in rural areas.
hotelsorinaroomrented bytheclient, whichisusually The main source of income in the province is from gold
attachedtotheentertainmentvenues.Ifthewomanwants mining and cement, sugar production and rubber plants
to join the client after the bars close, they can also go (3).In2003,careandsupportforpeoplewithHIV/AIDS
together to other settings. The street-based FSWs are was initiated in a pilot project providing antiretroviral
women who work outdoors at night on the streets or treatment (ART) in Kaysone Phomvihan, the main
parks in cities and towns. These women find clients district of the province. In addition, aprogramme called
through their own contacts, entertaining them in guest- ‘100% condom use program’ was implemented (9).
houses or hotels. Studies from Laos have found that In2006,adrop-incentreopenedinKaysonePhomvihan.
FSWs are vulnerable to sexually transmitted infections The centre uses a peer education approach and has
(STIs) and other health problems, including adverse established services primarily aimed at FSWs. The ser-
consequences of unsafe abortion and violence as well as vicesincludevoluntarycounsellingandtesting(VCT)for
encounteringsocio-economicdifficulties(7,10).Further- HIV, and behaviour change and communication (BCC)
more, access to healthcare and information services is activities also designated forother groups such as blood
limitedandinfluencedbythehigh costoftreatmentand donors, migrant workers and hospital patients suspec-
judgmental attitudes of healthcare providers (8, 11). ted of having HIV, and those requesting anonymous
Laos is a low HIV prevalence country, with 0.2% of tests. Condom distribution and STI treatment is also
adults aged 15(cid:2)49 estimated to be HIV positive (12). available free of charge to patients. However, if medica-
In 2004, an HIV prevalence of 3.9% was detected in tion is limited or not available, the patients will get a
FSWs, whereas the prevalence of other STIs such as prescription and be requested to buy the recommended
chlamydiaandgonorrhoeainthesamegroupwas33and medicinesinapharmacyusingtheirownmoney.In2007,
18%, respectively (13). The principle form of STI and theVCTprogramwasimplemented,andthusfar,21,185
HIVtransmissioninLaosisthroughsexualcontactwith personshavebeentested.ThecumulativenumberofHIV
an infected partner. The government of Laos has positivepeopleinSavannakhetis1,114,ofwhich58%are
approveda National Strategic and Action Plan on HIV/ women(15).ThemajorityofthosewhoareHIVpositive
AIDS/STI for 2011(cid:2)2015 aimed at expanding national are FSWs and migrant workers. Kaysone Phomvihan
capacity for universal access to treatment, care and district was chosen as the study site because there are
support without discrimination (14). The target groups many entertainment places in this district where FSWs
are FSWs, mobile populations and men who have sex work and live. Although there are two types of FSWs in
with men. Despite these efforts, FSWs in Laos delay Laos, there are no street-based FSWs in Savannakhet
seeking careand sometimes donot seekcareat allwhen province.
facedwithsexualandreproductivehealthproblems(11).
Treatment-seeking behaviour may be affected by several Studydesignandresearchteam
factors, including social norms and health system bar- A qualitative study using in-depth interviews was per-
riers. Itisnot known howFSWsinLaosperceive health formedtogainbetterunderstandingaboutperceptionsof
and illness and how this could be related to treatment- health/ill-health among FSWs. A qualitative approach is
seeking behaviour. Understanding FSWs’ perceptions of exploratory in nature and concerned with why the
health/illnessisthusrelevantforplanningandpromoting subjects being studied behave as they do, focusing on
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Healthiswealthandwealthishealth
perceptions,attitudes,beliefs,fears,andexperiences(16). problem and working as sex workers at the time of the
Theresearchteamcomprised oftwopeereducatorswho interview were purposively invited for an interview.
previouslyusedtoworkasFSWs,onefemaleinterviewer Before data collection started, the female interviewer
who had a background in social sciences, two Lao and the peers participated in a 3-day training session on
researchers (KP, VP) with a medical background and methods of qualitative interviews and how to approach
experiences in public health research and two Swedish potential interviewees. This training was led by the first
researchers (EF, ST), specialists in international public author (KP). In order to test the procedure and the
health research, specifically sexual and reproductive interview guide, the interviewer conducted three pilot
health aspects. The peer educators worked for the drop- interviews.Thepre-testresultsweresharedwiththewhole
in centre and had daily contact with FSWs in the researchteamandsomequestionswererevisedtoensure
study area distributing condoms and providing health thattheguidewassuitable,culturallyacceptable,andthe
information. wordsusednottoosensitive.Resultsfromthesepilotsare
not included in the analysis. After appointments were
Procedureandparticipants made with the potential participants, three could not
The two peer educators obtained information about the participate due to time constraints; one moved home
numberandtypeofentertainmentplacesfromthedrop- withoutgivinganycontactinformation,andtwodeclined
incentre.Withthesupportofthepeers,theresearchteam because their boyfriend objected. Thus, 15 women were
member whovisited FSWs’residence andworking place interviewed.
contacted FSWs. During a 2-week initiation period,
approximately 10 entertainment places in the study area Datacollection
were visited. The Lao research team members took the TheinterviewswereconductedduringJuly(cid:2)August,2008,
time to talk and listen to the women describing their in a location convenient for the women where a con-
health concern, for example, if they had any health versationcouldbeheldinprivacy(mostlyinthewomen’s
problems,theirworkingcondition,andtheirfutureplan. homeoratherworkplace,i.e.inalivingroomorbehind
The women who believed and reported having ill-health thebar).Thefemaleinterviewerexplainedthepurposeof
for example, complaining about headache, sleeping the interviewand its procedures. The women wereasked
problem, abdominal pain, vaginal discharge, itching, to describe what being healthy and having ill-health
pain during urinating were recorded for more visits. meant to them, and what they believed signified good/
These first informal discussions with the women created bad health. Each participant was encouraged to discuss
rapport and provided information in order to identify issues that were important to them. During each inter-
potential women to be interviewed. Our aim was to view, interesting information that emerged was probed
achieveasamplewithmaximumvariationregardingage, andfollowedup.TheinterviewswereheldinLaotianand
marital status, duration of work as FSW, and type of lasted between45 and 90 min. The interviewsweretape-
work place (Table 1). Twenty-one women who reported recordedwith the participants’ approval, and noteswere
illnesses including a sexual and reproductive health also taken.
Table1. Backgroundof the participants
No Participants’workingplace Age(year) Maritalstatus DurationofworkingtimeasFSW
1 Beerbar&nightclub 32 Divorced(2children) 1year
2 Beerbar&nightclub 30 Divorced(1child) 3years
3 Karaokebar&guesthouse 25 Single 7months
4 Beerbar&guesthouse 25 Divorced(1child) 2years
5 Beerbar&nightclub 27 Divorced 4months
6 Beerbar 26 Single 3years
7 Beerbar&restaurant 24 Divorced(1child) 2years
8 Beerbar 21 Single 3years
9 Beerbar&restaurant 35 Single 10years
10 Beerbar&guesthouse 18 Single 4months
11 Beerbar&restaurant 21 Single 1month
12 Beerbar&nightclub 23 Widow(1child) 1,5years
13 Beerbar 25 Divorced(2children) 1year
14 Beerbar&restaurant 22 Divorced 1month
15 Beerbar 25 Married 6years
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Dataanalysis Table2. Theanalysis processof categories, subthemes and
The tapes were transcribed into Laotian and then theme
translated into English and shared with the English-
speakingresearchteammembersinordertovalidatethe Theme Healthiswealthandwealthishealth
analysis. The text was analysed using latent content
analysis, whichfocuses ondescriptionand interpretation Sub-themes Healthwasnecessary Ill-healthcreatessocial
of underlying meanings of the text (17). This method forworkandincome andeconomic
enables the researcher to compare different concepts in vulnerability
thetexttowardanaccurateunderstandingofthewomen’s Categories Perceptionsofgood Perceptionsofill-health
perceptions. The first author initiated the analysis by health
readingthetranscriptsofthe interviewsseveraltimes. In Goodhealthmakes Ill-healthcancause
order to minimize misinterpretations during reading, the oneattractivetoclients socialdisapproval
LaotianandEnglishversionswereusedside-by-side.The Whatcontributesto
meaning units were identified and highlighted. Coding goodhealth
was done initially by the first author and followed by a
public health specialist (EF) reading the English tran-
reported that good health and physical fitness were
scripts and the codes. The codes that reflected the core
necessary to be a sex worker and explained the strong
meanings of the interview text were identified, and
relationshipbetweenhealthandworkcapacity.Below,we
grouped into categories, subthemes and atheme. During
present sex workers’ explanations of how they perceive
analysis, the research team discussed the procedures and
good health.
the findings until they reached agreement.
Perceptionsofgoodhealth
Participantprotection
The interviewed sex workers perceived health as the
Before the study was implemented, the National Ethics
absence of disease especially being free from STIs. One
Committee for Health Research, Laos, the Regional
woman explained:
Ethics Committee in Stockholm, and the local authority
in Savannakhet province approved the verbal consent Health is aperson who has no disease ‘a condition
procedure of the study. Verbal consent was sought from absent from any sign of a disease’ and not infected
each participant prior to interviewing and they were with STIs and physically looking well. [Beer bar &
nightclub FSW, aged23]
assuredthatdiscussionswouldbekeptconfidential.They
werealsoinformedthattheirparticipationwasvoluntary Some women understood health as a combination of
and that they could withdraw from the interview at any severalaspectssuchasbeingabletoeat,sleep,andsellsex.
time without any consequences. No written consent was
Thehealthypersoncansleep,drinkalcoholandshe
obtained, reflecting the sensitive nature of sex work and
cangoout‘havingsex’withmanyclients.[Beerbar
theriskthattheinformantswouldfearsanctionsastheir FSW,aged25]
work is illegal.
Most participants reflected that staying healthy was
necessary for being able to work. Good health allowed
Results
them to be able towork for long hours:
Onemaintheme(cid:2)‘healthiswealthandwealthishealth’(cid:2)
Good health means that you can work and work
emerged from the analysis. Health was considered
better than people who are not healthy, you can
necessary in order to attract clients. On the other hand,
makeagood income. [Nightclub FSW,aged27]
money was needed in order to pay for treatment when
sick and thus money was a prerequisite for health. The Another FSW from abeer bar said:
participants’ responses regarding health and ill-health Goodhealthmeansyoudon’tlosetimeanddonot
weregroupedundertwosub-themes:‘healthisnecessary havetopayformedicine.Youcangooutandenjoy
for work and income’ and ‘ill-health creates social and withyourfriends.[Beerbar&nightclubFSW,aged
economic vulnerability’ (Table 2). Participants perceived 23]
health as the ability to work and support their families
whileill-healthcreatedsocialandeconomicvulnerability. Goodhealthmakesoneattractivetoclients
The findings are presented below with quotations in Many sex workers explained that good health and
order to illustrate these two aspects. physical fitness were necessary to be attractive as a sex
worker. As one described:
Health is necessary for work and income
I think that when I am healthy, clients will see my
Health was defined as a condition that is needed to be fresh face, and then they will want me to sit and
able to work and collect money. Almost all participants serve beer for them. Clients like healthy and
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beautiful girls; theyget satisfied andwill ask me to Ill-healthcreatessocialandeconomicvulnerability
gooutforsex. [BeerbarFSW,aged25] The sex workers interviewed emphasized that ill-health
The participants considered that being young and affected their ability towork causing financial problems,
beautiful made them sexually attractive but it was also which in turn limited their ability to support their
an essential element to show their health status, which families. Ill-health also created barriers to socializing
leads to higher income. when returning home.
Those who are young and beautiful always receive
more clients. Clients believe that being young and Perceptionsofill-health
beautifulisclean,havingnodisease.Thentheywill Almost all sex workers interviewed defined disease as
selectyou.[Karaokebar&guesthouseFSW,aged18] having an abnormal sign or symptom appearing in their
Many women stated that health is important for their body. They described how a disease could present itself
business. Those who are healthy usually get higher through a feeling or an observable sign as one woman
income than those who are not healthy. described:
Icanseemanygirlswhoearninsufficientlybecause Whenyouhavefeverorheadacheitmeansthatyou
of not healthy, they were sick and had vaginal have a disease. [Karaoke bar & guesthouse FSW,
symptoms. Theycannot work,receivedlow income aged25]
and cannot afford treatment; they had never had a Women recognized that having a disease such as an STI
chance.[Nightclub FSW, aged27] has special signs:
I have a women disease, ‘STI’. The signs of this
Whatcontributestogoodhealth disease are discharge, vaginal itching and pain
The participants described several aspects that could during intercourse. [Beer bar & nightclub FSW,
support their health. One of the most important aspects aged30]
was money. Money meant that they could afford Another sex worker said she knew she had a disease
healthcare services and pay for other costs when ill. becausethedoctorhadtoldherwhenshevisitedahealth
Money was perceived as avital element, as described in clinic:
the following quote:
ThedoctortoldmethatIhaveadisease*‘thevagi-
Moneycanhelpmebeinghealthy.IfIhavemoneyI nal infection’*and needed to take some medicine
can afford good treatment services when I have foramonth.[Beerbar&guesthouseFSW,aged25]
health problems. If I don’t have money, how can I
Some participants did not understand what ill-health
handlemyillness?[Beerbar&restaurantFSW,aged
meant:
24]
Could you explain to me how this is so? I don’t
Somesexworkersemphasizedthatinordertobehealthy
know’. [Beerbar& guesthouseFSW, aged18]
theyshouldusecondomstopreventdiseaseswhenhaving
sex with clients. Also health controls were considered However, other women had a clear view about ill-health
important. and what ill-health meant to them as illustrated in the
quote below:
TobehealthyItriedtousecondomswhenhavingsex
withclients.Ikeephealthybygoingforregularhealth Ill-health is a disease, ill-health means you suffer
check-ups.[Beerbar&restaurantFSW,aged35] from diseases such as headache and vaginal dis-
charge. [Karaokebar& guesthouse FSW, aged25]
The women mentioned that the reason why their health
was not good was that they drank alcohol and had sex Some sex workers were concerned about the impact of
with many clients every day. Some argued that although ill-health on their working capacity:
money was important, eating adequate and good food
When you get sick you cannot drink beer and
was also important for maintaining good health. providegood services ‘sexwithclients’, youcannot
earnbutyoulose.Instead,youhavetovisitahealth
What I can do in order to be healthy is eat good
food like beef, pork, chicken or fish with some facilityandpayfortreatmentservicesandmedicines
and you will lose money. [Beer bar & nightclub
vegetables and also fruitandmilk. [Karaokebar&
FSW,aged23]
guesthouse FSW,aged25]
Being sick was perceived as a catastrophe by the
Somewomensaidthatinordertobehealthytheyneeded
participants because the bar owners or pimps told sick
physical exercise, enough sleep and a clean living
women to stop working or move out of the bar to avoid
environment. However, most women claimed that this
their business getting abad reputation:
wasnotpossibleintheircurrentworkingsituation.Some
womenalsomentionedthatthebestthingfortheirhealth When sick, I could not work and have sex with
would be if they could leave sex work. clients. The bar owner asked me to stop working.
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I wanted to move to another bar but that was not support their family. One woman, aged 23, from a beer
possible because the bar owners would not accept bar and nightclub reported:
me,theywouldnotacceptasickwoman.[Beerbar
AlthoughIwassick,IhavegenitalsymptomsbutI
& restaurant FSW,aged24]
will wait to visit health centre. I want to keep my
money to support my parents and my siblings.
Ill-healthcancausesocialdisapproval I don’t want to spend the money for my health
Fears of one’s profession being disclosed and worries now, I will wait as the symptoms still allow me to
about the impact of their work were common. Partici- work, there are many people were waiting for my
pants said that they didn’t want their family to know support.
abouttheirworkasitbroughtshameandembarrassment
Women commonly spoke about paying less attention to
to their parents and their family.
their health, that the diseaseswere not seriously treated,
When my parents knew about my job, they were especially STIs. Although a treatment may have been
veryirritated.Iwasalmostkilledandtheyscreamed initiated, being under treatment could interrupt their
at me ‘We have a bad daughter’. [Beer bar & ability to support their family. The health concern in
restaurant FSW,aged 35] illness of awoman gives the following account:
Most women experienced shame and disgrace when ill.
... according to treatment advised, I use supposi-
Theydescribedhowpeopleinthevillagesdisapprovedof
tory treatment for my abdominal pain and dis-
women returning to the village in poor health and often charge. I still go out for sexual intercourse with
associated ill-health in women with having a ‘bad’ job. clients. What I did is that, when arrived at a guest
Thismadethewomenreluctanttogohomewhenillsince house, in the toilet, the suppository tookout from
it could result in community insult. myvaginabeforehavingsexwithclient ...todilute
invaginaitneededatleasttwodays.[Nightcluband
When sick I do not go home, because I am afraid
guest house girl, aged25]
thatmyparentsandpeopleinthevillagewhereIlive
will know what happened to me. [Beer bar &
restaurant FSW,aged 24]
Discussion
Somewomenexplainedthatpeopleintheirvillagewould
According to the sex workers’ accounts, health was
criticize them if they had poor health. This created
clearly associated with the ability to work and earn an
barrierstosocializingbecauseoftheneedtoavoidpublic
income and that they interpreted health mainly in
insult or embarrassment. One of the women being
economic terms. The women perceived health as being
interviewed explained:
physically fit, beautiful, andwithout unpleasant physical
Beingsick,youcouldnotparticipateinthevillage’s symptoms. They also reflected that health was a combi-
activities nor socialize with your friends when you nation of several aspects such as being able to eat, sleep,
gohome.Peoplewillcomeandaskaboutyou.They and work, for example, selling sex. The perceptions of
willsuspectthatyouhaveabadjob‘sellingsex’and
health as expressed by the FSW in our study obviously
infected with AIDS. [Beer bar & nightclub FSW,
differ from the definition of health used by the medical
aged32]
profession (18). Our findings indicate how the women’s
Most participants revealed that although their income experiences and concerns about health and ill-health
washighitwasuncertain,andmanyneededtoreservea were related to their work. Similar findings have been
portion of their income to support their families as this found from other setting where FSWs interpreted their
could release social negative reaction. Meeting one’s health in relation to bodily qualities by saying, ‘I am
family’s needs could limit the opportunity for using young. My milk is standing. My body is good. No
healthcare services. Thus the traditional demand to take disease’ (19).
careofone’sfamilycreatedasituationwheregettingsick There were different perceptions of health described
meant not fulfilling one’s duties in societyas reported in by participants in the present study. Health was im-
the quote below: portant for financial purposes but health was also
Manygirlswhoworkinthisbardonothaveenough viewed as a key element in sex work because health
money when sick because they contribute their was a ‘client demand’ and something that made the sex
income to support their family. Of course, your worker attractive to clients. Our findings are consistent
parentsandpeopleinthevillagewillbeproudofthe with an ethnographic study in Madagascar (20), where
support ...Iftheyusedallthemoneyforhealthcare FSWs’ perceptions were influenced by personal identity,
then the family will be in trouble. [Beer bar FSW, socio-economic status and the environmental struc-
aged26]
ture in which they lived. Furthermore, Helman 2007
Mostparticipantsmentionedaboutdelayingtreatmentor describes that neither health nor illness are static
seekingcarebecausetheyneededtokeeptheirincometo constructs, but that both are influenced by a particular
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economic and social situation and also human char- ThefindingsalsoshowedFSW’sreasoninrelationtotheir
acteristics, experiences and beliefs (21). health, coping with ill-health and experiences of seeking
Participants in our study experienced both direct and careandtreatment*aspectsthatarecloselyconnectedto
indirect negative impacts of ill-health. The direct impact thewomen’sperceptionofhealth/ill-health.Examplesfor
reportedwas economic loss. This is because sex workers notseekinghelpincluded:‘don’tcareaboutthesymptoms
can neither take care of the bar duties or have sex with ofSTI/notimportant’,and‘don’twanttovisitthehealth
clientswhenill,whichinturnlimitstheirabilitytosupport centrebecauseafraidoftheresult’.Furthermore,reason-
their families. The indirect impacts of ill-health were ingbehindnotseekingcarewere,forexample,‘don’tknow
related to social relationships and emotional stress. Sex wheretogo’,‘judgmentalattitudeofhealthcareprovider’,
workershadnoticedthatpeopleintheirsocietyassociated and ‘inconvenient location’ (11). Poverty limits educa-
ill-health in women who returned home with improper tionalattainmentandasaconsequencealsolimitsaccess
behaviour,forexample,sellingsex.Thiscreatedbarriersto tothelabourmarket.Womenfromfamilieswithlowsocial
socializing because of the need to avoid public insult or andeconomicstatusareparticularlyaffected(27).Beinga
embarrassment. Sex workers’ descriptions of ill-health womaninanillegaljobmeansfacingenormousobstacles,
indicatetheimportanceofunderstandingculturalnorms including high-risk situations and becoming ill, which
andpracticesrelatingtoill-healthinourstudycontext. could result in termination of their work by their
The women not only included their own experiences employer. Ironically, even though the participants knew
and perceptions of ill-health, but also the meaning that thattheirworkwasmorallywronganddisgracefultothem
others around them associated with ill-health. Ill-health andtheirfamilies,theyneededtokeepthejobnotonlyfor
often shares the psychological, moral and social dimen- theirownsurvivalbutalsoforthesurvivaloftheirfamily.
sions associated with other forms of adversity within a
particular society. In a study on tuberculosis in Bangla-
Methodological considerations
desh and Vietnam, patients reported feeling ashamed or
Using qualitative, in-depth interviews allowed partici-
embarrassedbecauseofthedisease.Theclinicalperspec-
pants to discuss their perceptions, providing insight into
tive was less reported, but their feeling of being socially
their experiences and concerns. Spending time to visit,
ostracizedwasamajorconcern(22,23).Ourfindingsare
talkandlistentothewomendescribetheirhealthproved
important since they suggest that ill-health is a wider,
to be a valuable and successful procedure to create
more diffuse concept than just disease. This should be
rapport so that participants would openly discuss their
taken into account inunderstanding how FSWs in Laos
perceptions about health. In addition, allowing partici-
interpret their ill-health and how this interpretation
pants to select the venue for the interviews created an
might influence their care seeking.
environment where the women could freely discuss
In contexts where there is unequal distribution of
personal issues. Discussing sex-related matters is sensi-
wealthandresources,obligationstosupportone’sfamily
tive. Therefore, we involved peer educators who used to
are of utmost importance for the survival of the family.
work as FSWs and a female interviewer with a back-
TheresultsfromastudyinVietnamsuggestedthatFSWs
ground in social science to enhance the validity of the
engaged in transactional sex because of the need to
findings.Findingsfromthisstudystemfromwomenwho
supportsibling’sschoolfees,payingforanewhouse,and
presently reported ill-health. Therefore, it is the views of
payingthefamily’sdebt(24).Apreviousstudyconducted
those who had a health problem. Those who had left
inPakistanindicatedthatpoverty,financialburdens,and
work because of serious illness or were healthy were not
a desire to survive forced women into prostitution (25).
included. Despite this, the study provided valuable
Beingabletosupportthefamilymadeparticipantsproud
information about perceptions of health and ill-health
and gave them social value. However, this obligation
among FSWs in Laos. We believe that what the partici-
might lead to high-risk sexual behaviour. For instance,
pants shared is also valid for FSWs in other similar
when FSWs urgently need money to pay the family’s
settings.
debts or to pay for siblings’ school fees they may force
themselves to work harder and also engage in unpro-
tected sex (7). Another study found that when clients Conclusions
refusedtouseacondom,FSWschargedmoremoneyand Femalesexworkers’beliefsandperceptionsabouthealth
went ahead having sex without a condom (26). and ill-health were dominated by their economic need,
Many participants indicated that they do not have which in turn was influenced by expectations and
enoughmoneywhensick.Theysometimesdelayedtreat- demands from their families. The obligations to support
mentforSTIsinordertoreserveaportionoftheirincome one’s family threaten FSWs’ health and social and
fortheirfamily.Thisfindingisconsistentwithresultsfrom financial security. Our findings regarding FSWs’ percep-
apreviousstudyconductedbytheauthors,whichshowed tions about health and ill-health can be used in health
that20%ofFSWsdelayedtreatmentduetolackofmoney. promotion programs for FSWs.
7
Citation:GlobHealthAction2013,6:19080-http://dx.doi.org/10.3402/gha.v6i0.19080
(pagenumbernotforcitationpurpose)
KetkesonePhrasisombathetal.
Acknowledgements transmitted infections among female sex workers in Laos: a
cross-sectionalstudy.BMCHealthServRes2012;12:37.
12. UNAIDS (Joint United Nations Programme on HIV/AIDS)
Wearegratefultothesewomenforspendingtheirvaluablewithus
andforsharingsomuchoftheirlives.Wethankthepeereducators (2008).Reportonthe GlobalAIDSepidemic. Availablefrom:
andtheDirectoroftheProvincialHealthDepartment,Savannakhet http://www.data.unaids.org[cited20July2012].
province, for the support given to this study. We thank Birgitta 13. CHAS (Center for HIV/AIDS/STI) (2004). Second HIV sur-
Rubenson,EvaJohanssonandAnnikaJohanssonfortheirvaluable veillance survey and sexually transmitted infections periodic
commentson the manuscript. We wish to thank Lidavone Silitha- prevalence survey, Ministry of Health, Lao PDR; 2004.
sack and Soukdavanh Phrasisombath for their helpful feedback. Availablefrom:http://www.fhi.org[cited16May2012].
This investigation received financial support from the Swedish 14. National Committee for the Control of AIDS Bureau
International Development Cooperation Agency (Sida) and the (NCCAB). National strategic and action plan on HIV/
UniversityofHealthSciences,Laos. AIDS/STI for 2011(cid:2)2015. Ministry of Health, Lao People’s
DemocraticRepublic;2005.
Authors’ contributions 15. Provincial Committee for the Control of AIDS (PCCA).
Secretariat of HIV/AIDS and STIs Prevention and Control
KPisthemainauthor;hedevelopedtheresearchdesign,
Unite,SavannakhetProvince,MinistryofHealth,LaoPeople’s
prepared data collection, supervised research assistants
DemocraticRepublic;2008.
during data collection, carried out the analysis, and 16. Patton MQ. Qualitative evaluation and research methods. 3rd
drafted the manuscript. EF, ST, and VS assisted with ed.ThounsandOaks,USA:SagePublications;2002,pp.209(cid:2)541.
the research design, collaborated in the analysis and 17. Graneheim UH, Lundman B. Qualitative content analysis in
nursingresearch:concepts,proceduresandmeasurestoachieve
offered critical comments in reviewing the manuscript.
trustworthiness.NurseEducToday2004;24:105(cid:2)12.
18. WHO(WorldHealthOrganization)(2011).Definitionofhealth.
Conflict of interest and funding
Available from: https://apps.who.int/aboutwho/en/definition.
The authors have declared that no competing interests html[cited23November2011].
exist. 19. Sulusi-SjoJ.CommercialsexworkinDaresSalaam,Tanzania:
a case study of hotel-and street-based comercial sex workers.
Unpublish master thesis, Linkopings University, Linko¨ping,
References Sweden,2000.
20. StoebenauK.Symboliccapitalandhealth:thecaseofwomen’s
1. LaoNationalStatisticCenter.Basicstatistics2005.LaoPeople’s sexworkinAntananarivo,Madagascar.SocSciMed2009;68:
DemocraticRepublic;2005. 2045(cid:2)52.
2. NationalInstituteofPublicHealth(NIOP).Healthstatusofthe 21. Helman C. Culture, health and illness. 5th ed. Oxford, UK:
people in Lao PDR. National Health Survey, Ministry of OxfordUniversityPress;2007,pp.126(cid:2)54.
Health,LaoPeople’sDemocraticRepublic;2005. 22. Karim F, Johansson E, Diwan VK, Kulane A. Community
3. PovertyinLaoPDR.Laoexpenditureandconsumptionsurvey perceptions of tuberculosis: a qualitative exploration from a
1992/03(cid:2)2007/08.LaoPDR:DepartmentofStatistics,Ministry genderperspective.PublicHealth2011;125:84(cid:2)9.
ofPlanningandInvestment;2008. 23. Long NH, Johansson E, Diwan VK, Winkvist A. Fear and
4. Sychareun V. Meeting the contraceptive needs of unmarried socialisolationasconsequencesoftuberculosisinVietNam:a
youngpeople:attitudesofformalandinformalsectorproviders genderanalysis.HealthPolicy2001;58:69(cid:2)81.
in Vientiane Municipality, Lao PDR. Reprod Health Matters 24. Rubenson B, Hanh LT, Hojer B, Johansson E. Young sex-
2004;12:155(cid:2)65. workersinHoChiMinhCitytellingtheirlifestories.Childhood
5. Sychareun V, Phongsavan K, Hansana V, Phengsavanh A. 2005;12:391(cid:2)411.
Policy maker and provider knowledge and attitudes regarding 25. Khan MS, Johansson E, Zaman S, Unemo M, Rahat NI,
theprovisionofemergencycontraceptivepillswithinLaoPDR. Lundborg CS. Poverty of opportunity forcing women into
BMCHealthServRes2010;10:212. prostitution*a qualitative study in Pakistan. Health Care
6. ChenJ,LongfewK,PX.Sexualbehavioursamongfemalesex
WomenInt2010;31:365(cid:2)83.
workersinLaoPDR.Vientiane,LaoPDR:ThePSIDashboard,
26. Rosenthal D, Oanha TT. Listening to female sex workers in
ResearchDividionPopulationServicesInternational;2005.
Vietnam: influences on safe-sex practices with clients and
7. Phrasisombath K, Faxelid E, Sychareun V, Thomsen S. Risks
partners.SexHealth2006;3:21(cid:2)32.
benefitsandsurvivalstrategies*viewsfromfemalesexworkers
27. KrishnanS,DunbarMS,MinnisAM,MedlinCA,GerdtsCE.
inSavannakhetLaos.BMCPublicHealth2012;12:1004.
Padian NS: Poverty, gender inequities, and women’s risk of
8. PhrasisombathK,ThomsenS,HagbergJ,SychareunV,Faxelid
humanimmunodeficiencyvirus/AIDS.AnnNYAcadSci2008;
E.Knowledgeaboutsexuallytransmittedinfections(STIs)and
1136:101(cid:2)10.
attitudestowardfemalesexworkerswithSTIsymptomsamong
health care providers in Laos. Asia Pac J Public Health 2011.
DOI:10.1177/1010539511416223. *KetkesonePhrasisombath
9. Phimphachanh C, Sayabounthavong K. The HIV/AIDS/STI FacultyofPostgraduateStudiesandResearch
situation in Lao People’s Democratic Republic, AIDS Educ UniversityofHealthSciences
Prev2004;16(3SupplA):91(cid:2)9. POBox7774
10. MorineauG,NeilsenG,HengS,PhimpachanC,Mustikawati Vientiane,Laos
DE.Fallingthroughthecracks:contraceptiveneedsoffemalesex Tel:((cid:3)856)2022215234
workersinCambodiaandLaos.Contraception2011;84:194(cid:2)8. Fax:((cid:3)856)21240854
11. Phrasisombath K, Thomsen S, Sychareun V, Faxelid E. Care Email:[email protected],
seekingbehaviourandbarrierstoaccessingservicesforsexually [email protected]
8
Citation:GlobHealthAction2013,6:19080-http://dx.doi.org/10.3402/gha.v6i0.19080
(pagenumbernotforcitationpurpose)