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Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs.
Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June–December 2019), midline (n = 366) (Jan–March 2020) and endline (n = 877) (June 2020–Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours.
There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37–2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55–3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31–2.95), recent hunger (aOR 1.69; 95% CI 1.15–2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00–2.23).
Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence.
Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance are associated with poor mental health outcomes in the general population. These risks are likely to be exacerbated among Female Sex Workers (FSWs), however there are few studies examining risks factors for mental health problems among FSWs. We examine the prevalence and correlates of common mental health problems including suicidal behaviour among FSWs in Kenya.
Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline data were collected from June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, and the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD). Recent suicidal behaviour was defined as reported suicide attempt or suicidal ideation in the past 30 days. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the WHO ASSIST tool (to measure harmful alcohol/substance use in the past 3 months). Descriptive statistics and multivariable logistic regression were conducted in Stata 16.1.
Of 1039 eligible FSWs, 1003 FSWs took part in the study (response rate: 96%) with a mean age of 33.7 years. The prevalence of moderate/severe depression was 23.2% (95%CI: 20.7–25.9%), moderate/severe anxiety 11.0% (95%CI: 9.3–13.1%), PTSD 14.0% (95% CI: 12.2–16.5%) and recent suicidal behaviour 10.2% (95%CI: 8.5–12.2%) (2.6% suicide attempt; 10.0% suicidal ideation). Among women with any mental health problem 63.0% also had a harmful alcohol/substance use problem. One in four women (25%; 95%CI: 22.5–27.8%) had depression and/or anxiety and this was independently associated with higher ACE scores, hunger (skipped a meal in last week due to financial difficulties), death of a child, perceived sex work stigma and recent sexual/physical violence. PTSD was associated with higher ACE scores, hunger, increased STI prevalence (chlamydia trachomatis) and recent violence. Recent suicidal behaviour was associated with higher ACE scores, low literacy, hunger, and recent violence. Mental health problems and suicidal behaviour were less prevalent among women reporting social support.
The high burden of mental problems among FSWs indicates a need for accessible services tailored for FSWs alongside broader structural interventions addressing poverty, harmful alcohol/substance use and violence. High rates of ACEs among this population indicates the need to consider early childhood and family interventions to prevent poor mental health outcomes.
Funding: Medical Research Council and the UK Department of International Development
This study examines the prevalence and associations between recent violence experience, mental health and physical health impairment among Female Sex Workers (FSWs) in north Karnataka, India.
Multi-morbidity, in particular the overlap between physical and mental health problems, is an important global health challenge to address. FSWs experience high levels of gender-based violence, which increases the risk of poor mental health, however there is limited information on the prevalence of physical health impairments and how this interacts with mental health and violence.
We conducted secondary analysis of cross-sectional quantitative survey data collected in 2016 as part of a cluster-RCT with FSWs called Samvedana Plus. Bivariate and multivariate analyses were used to examine associations between physical impairment, recent (past 6 months) physical or sexual violence from any perpetrator, and mental health problems measured by PHQ-2 (depression), GAD-2 (anxiety), any common mental health problem (depression or anxiety), self-harm ever and suicidal ideation ever.
511 FSWs participated. One fifth had symptoms of depression (21.5%) or anxiety (22.1%), one third (34.1%) reported symptoms of either, 4.5% had ever self-harmed and 5.5% reported suicidal ideation ever. Over half (58.1%) reported recent violence. A quarter (27.6%) reported one or more chronic physical impairments. Mental health problems such as depression were higher among those who reported recent violence (29%) compared to those who reported no recent violence (11%). There was a step-wise increase in the proportion of women with mental health problems as the number of physical impairments increased (e.g. depression 18.1% no impairment; 30.2% one impairment; 31.4% ≥ two impairments). In adjusted analyses, mental health problems were significantly more likely among women who reported recent violence (e.g. depression and violence AOR 2.42 (1.24–4.72) with rates highest among women reporting recent violence and one or more physical impairments (AOR 5.23 (2.49–10.97).
Our study suggests multi-morbidity of mental and physical health problems is a concern amongst FSWs and is associated with recent violence experience. Programmes working with FSWs need to be mindful of these intersecting vulnerabilities, inclusive of women with physical health impairments and include treatment for mental health problems as part of core-programming.
Samvedana Plus was funded by UKaid through Department for International Development as part of STRIVE (structural drivers of HIV) led by London School of Hygiene and Tropical Medicine and the What Works to Prevent Violence Against Women and Girls Global Programme led by South African Medical Research Council
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