Water, sanitation and hygiene at sex work venues to support menstrual needs

Abstract

Introduction: Adequate menstrual health and hygiene (MHH) is necessary for women's health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya.

Methods: Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor's consent. WASH scores ranging 0-3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests.

Results: Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine; and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities.

Discussion: WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed.

Trial registration: Clinicaltrial.gov NCT0566678.

Keywords: female sex workers; menstrual health and hygiene (MHH); reproductive tract infections; sanitation and hygiene (WASH); sexual and reproductive health; waste disposal; water.

Figure 1

Examples of latrines and classification of acceptability and usability. (A) This latrine from a Guest House and Bar was classified as unacceptable and unusable: the flooring was unstable, there were holes in the walls, there was no functional lighting, and it was very unclean with strong smell of urine and feces. Notably, this latrine was also shared with the community tenants. (B) This latrine from a Bar was classified as unacceptable and unusable: the floor was very unstable (“can sink at anytime” was noted by investigators doing the assessment), the door had no lock, and it was very unclean and had a strong smell of urine and feces. (C) This latrine from a Brothel was classified as unacceptable but usable: It was very unclean with urine on the floor, pungent smell of urine and faces, and no functional lighting. (D) This latrine (labeled as “Ladies”) from a Guest House and Bar was classified as usable and acceptable: being somewhat clean, no strong odors of urine or feces, locking door, stable flooring, no holes in wall, and functional lighting. Investigators also noted a covered bin for disposal of MHH materials. At this venue, water was available, but soap was not. (E) This latrine from a Guest House, Restaurant, and Bar was classified as acceptable and usable: a wall separated male and female toilets, flooring was stable, doors were lockable, there was functional lighting and no strong smell of urine or feces. A handwashing point was located outside the latrines, and water was available but not soap. This venue had multiple handwashing points and the one near the restaurant had water and soap available. Additionally, there were handwashing points near or inside the guest rooms with both water and soap available. (F) This latrine at a Brothel is usable but unacceptable. It was clean with no smell of urine, and stable flooring, but with no door, no functional lighting, and limited privacy. While not directly applicable to females, we provide this example of a urinal as it was representative of several urinals observed. (G) This latrine from a Restaurant and Bar was classified as acceptable and usable: very clean, with locking door, stable flooring, functional lighting, and a covered bin for disposal of used menstrual materials. There were multiple handwashing points with water and soap. (H) The latrine at this Bar was classified as usable and acceptable: very clean, with functional lighting, locking door, stable flooring, a covered bin for disposal of used menstrual materials, and handwashing facilities with water, soap, and a towels for drying hands. (I) The latrine at this Bar was classified as usable and acceptable: very clean, with functional lighting, locking door, stable flooring, a covered bin for disposal of menstrual materials, and handwashing facilities with water, soap, and a functional, air-blowing hand dryer available. The photographs were taken using the study tablets via the ODK programming, with express permission of the venue proprietors who consented to the WASH assessment.

Figure 2

Distribution of WASH score by venue type. The X-axis shows the percentage of venues meeting a particular WASH score, which is represented by the legend to the right. For example, for venues that are classified as Guest House and Bar (N = 4), 75% had a WASH score of zero and 25% had a WASH score of three.

Figure 3

Distribution of MHH score by venue type. The X-axis shows the percentage of venues meeting a particular MHH score, which is represented by the legend to the right. For example, for venues that are classified as Bar (N = 14), 43% had a MHH score of zero and 7% had a MHH score of one, 43% had a MHH score of 2, and 7% had a MHH score of 4.

Figure 4

Distribution of MHH score by WASH score. The y-axis shows the percent of venues having an MHH score ranging 0–4 (legend, right), stratified by WASH score ranging 0–3, as depicted on the x-axis. For example, among 16 venues with a WASH score of zero, nearly 70% of those also had a MHH score of zero.