G02.G05 CÀRREGA I TRANSPORT DE TERRES O RUNES

Consistent with studies in Chinese adolescents11 and unmarried youth39, SRH/FP knowledge was poor in our study population, and misconceptions were prevalent (Article 3, 4). Moreover, a lower level of SRH knowledge was associated with

inconsistently using condoms with paying partners, and not receiving SRH knowledge from traditional media. (Article 3). Despite participants reporting having received SRH/FP information from a range of sources, including school, traditional media, peers, family, and public or private SRH services, just 27% reported ever receiving any SRH/FP information from health providers. Furthermore, those reporting receipt of information from health providers seemed to report the poorest level of knowledge, relative to those receiving information from other sources, reflecting either limited access/weak SRH service delivery, or incomplete SRH knowledge of health providers/lack of effective SRH counselling (Article 3). In line with SRH studies among general adolescent population,11,12 our findings highlight a critical missed opportunity to provide essential services to this hard to reach population, and also suggest a need to improve the knowledge, attitudes and counselling skills of health providers which are also associated with low utilization of public health care services.

Nearly all adolescents (98%) reported not currently wanting to get pregnant. The majority of participants (91%) reported currently using condom, however only 40% of them consistently used condom with their sexual partners in the past month; with the exception of condoms and emergency contraception, current use of other modern contraception was very low (<10%); only 7% of adolescent FSWs were currently using dual protection (any modern contraception plus consistent condom use) with their sexual partners (Article 3). Our study show the inconsistent condom use with non-paying partners was significantly higher than with paying clients (88% vs. 45%). This is similar to reports from a previous study (ranging 78%-95% with stable non-paying partners) across street-based and establishment-based FSWs.22 Existing studies in south Asian countries indicate that ineffective contraceptive use, rather than non-use, contribute to unintended pregnancy: as many as two-thirds of abortions are due to contraceptive failure, mostly from traditional method use, and one-third are due to unmet need for contraception.40 It is clear that reliance on condoms with questionable compliance or emergency contraception, as well as the low level of uptake dual protection, significantly increased the risk of unplanned pregnancy and HIV/STI acquisition among adolescent FSWs

(Article 1, 2, 3).

Qualitative studies among young women in developing countries revealed that preserving future fertility is as important as preventing pregnancy, and condoms and traditional methods, which do not threaten fertility, are often relied on.35 Chinese literature revealed that douching remained the most used contraceptive method between FSWs and their stable non-paying partners (62%), followed by female condom.8 In our studies, the current use of traditional methods was common (40%) (Article 3), predominately for those who use drugs (Article 4). Comparing with previous studies in adolescents in developing counties or unmarried women in China,35,41-44 our studies demonstrated very low uptake of IUD and implants among adolescent FSWs: ever used (0% for IUD and 3% for implants) (Article 2); currently using (1% for IUD and 0% for implants) (Article 3). This phenomenon is due to low awareness and knowledge of LARCs (Article 3), and may also reflect the strong socio-cultural pressures to prove fertility among young women who have not yet to had a child but have concerns about potential side effects and health risks of the LARCs.35,44 In addition, younger adolescents were more likely to be non-users of modern contraception than older adolescent FSWs (Article 2). Previous studies suggest that discontinuation and poor compliance are particularly important reasons for higher failure rates and unintended pregnancy in adolescent women who use short-acting contraception including condoms and oral pills.45-47 Given the adolescents’ nature of lower sense of self-efficacy and confidentiality concern, as well as the occupational risk of sex work-unpredictable and irregular sexual activity, sexual coercion and violence, alcohol and other substance influence, the greater effects should be made to promote the uptake of LARCs, particularly couple with condom use among adolescent FSWs.

In addition, there is strong evidence that SRH and inconsistent condom use are affected by gender-based violence. In studies across India, Nepal and Thailand, young age at entry to sex work has been found to heighten vulnerability to physical and sexual violence victimisation in the context of prostitution, and relates to a two to four-fold increase in HIV infection.48,49 A cohort study with 367 FSWs in Kenya revealed that sexual and/or physical

violence by an emotional partner (boyfriend or husband) was experienced by over half (55.0%) of FSWs over the past year, and associated with higher number of sexual partners and inconsistent condom use.50 Research with other Chinese FSW has found the proportion ever experiencing violence to range from 16% to 58%.13,51,52 We also found that 38% of adolescent FSWs had experienced recent physical or sexual violence from sexual partners, this was associated with poorer assess to HIV/STI or FP consultation services (Article 3). Sexual and gender-based violence against FSWs is a pervasive and complex issue, and addressing this requires input from multiple sectors including the community, health, police and legal sectors. Interventions to prevent and protect from violence may include empowering FSW with knowledge about their rights and skills for negotiation, self-protection and strategizing responses training, peer support and information sharing, promoting workplace security, provision of legal support, public advocacy, and supportive legislation.16,25,53,54 In addition, health care providers and others working with FSW should be trained to refer victims of violence to appropriate health, psychosocial, and legal support. There is also a need for training in skills for condom/contraception negotiation among these adolescent FSW, as partner refusal to use condoms was common (Article 3).

4.1.4 Poor sexual and reproductive health