Article Text

Suboptimal access to primary healthcare among street-based sex workers in southwest Switzerland
  1. Katharine Elizabeth Anna Darling1,
  2. Elodie Gloor2,
  3. Anne Ansermet-Pagot3,
  4. Paul Vaucher4,
  5. Sophie Durieux-Paillard5,
  6. Patrick Bodenmann4,
  7. Matthias Cavassini1
  1. 1Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
  2. 2Faculty of Biology and Medicine of the University of Lausanne, Switzerland
  3. 3Association Fleur de Pavé, Lausanne, Switzerland
  4. 4Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
  5. 5Migrant Health Program, Department of Community Medicine and Primary Care, Geneva University Hospitals, Geneva, Switzerland
  1. Correspondence to Dr Katharine Darling, Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois,Rue du Bugnon 46, Lausanne 1011, Switzerland;Katharine.Darling{at}chuv.ch

Abstract

Objectives Street-based sex workers (SSWs) in Lausanne, Switzerland, are poorly characterised. We set out to quantify potential vulnerability factors in this population and to examine SSW healthcare use and unmet healthcare requirements.

Methods We conducted a cross-sectional questionnaire-based survey among SSWs working in Lausanne's red light district between 1 February and 31 July 2010, examining SSW socio-demographic characteristics and factors related to their healthcare.

Results We interviewed 50 SSWs (76% of those approached). A fifth conducted their interviews in French, the official language in Lausanne. 48 participants (96%) were migrants, of whom 33/48 (69%) held no residence permit. 22/50 (44%) had been educated beyond obligatory schooling. 28/50 (56%) had no health insurance. 18/50 (36%) had been victims of physical violence. While 36/50 (72%) had seen a doctor during the preceding 12 months, only 15/50 (30%) were aware of a free clinic for individuals without health insurance. Those unaware of free services consulted emergency departments or doctors outside Switzerland. Gynaecology, primary healthcare and dental services were most often listed as needed. Two individuals (of 50, 4%) disclosed positive HIV status; of the others, 24/48 (50%) had never had an HIV test.

Conclusions This vulnerable population comprises SSWs who, whether through mobility, insufficient education or language barriers, are unaware of services they are entitled to. With half the participants reporting no HIV testing, there is a need to enhance awareness of available facilities as well as to increase provision and uptake of HIV testing.

  • Sexual Medicine

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Introduction

Street-based sex workers (SSWs), as opposed to individuals who sell sex indoors (salons and bars), are made vulnerable through factors such as social marginalisation and fear of stigmatisation.1 ,2 Many have not completed obligatory schooling.3 Compared with ‘indoor’ sex workers, SSWs experience more acute and chronic illness.4 ,5

In Switzerland, commercial sex work is a legal activity in certain cantons provided it occurs within demarcated zones and during designated nocturnal hours.6 ,7 An estimated 14 000–20 000 commercial sex workers currently practise (street-based and indoors).8 ,9 In Lausanne, the capital of the canton of Vaud, sex work is permitted in a single district between 22:00 and 5:00.10 In 2008, police records estimated that 250 SSWs were practising in this city; it is possible that current figures are higher.11

In central Lausanne, two organisations funded by public–private partnerships operate to support SSWs: the Fleur de Pavé association operates a mobile van parked in Lausanne's red light district five nights a week, providing condoms, needle exchange and psychosocial support, and the Point d'Eau centre offers free primary healthcare, including gynaecology care, to all individuals, even those lacking residence permits and/or health insurance. Normally, Switzerland operates an insurance-based healthcare system whereby individuals with no health insurance must pay for their healthcare, from clinic or hospital visits to prescribed treatments.

Official data regarding the demography and health of Lausanne's SSWs are lacking. We conducted a survey to better characterise this population, examining socio-demographic characteristics and access to healthcare: knowledge of healthcare facilities, healthcare use and perceived healthcare needs, and HIV testing history.

Methods

Ethics statement

All SSWs invited to be interviewed (hereafter referred to as, ‘participants’) were informed that the questionnaire would be conducted anonymously (see online supplementary file). Owing to the anonymous nature of the questionnaire, consent was verbal rather than written, participation taken as implicit consent. The study protocol was approved by the Ethics Committee of the University of Lausanne, Switzerland.

Study design, setting and participants

We conducted a prospective cross-sectional questionnaire-based survey among SSWs attending the Fleur de Pavé van in the red light district of Lausanne, Switzerland, from 1 February to 31 July 2010. The study took place between 22:00 and 2:00 in the van, and during the day in the Fleur de Pavé offices in central Lausanne. SSWs who met study inclusion criteria (see below) were invited by EG or a member of the Fleur de Pavé team to take part in a face-to-face questionnaire. It was explained that the questionnaire was to examine access to healthcare for SSWs and to understand who makes up this population. SSWs agreeing to participate attended the Fleur de Pavé offices during the day to complete the questionnaire. The questionnaire took approximately 10 min to complete with Portuguese, Spanish, Romanian or English translation offered to non-French speakers. If, at the end of the questionnaire, the interviewer noted a lack of knowledge of available healthcare networks, the interviewee was given a leaflet with addresses of healthcare providers and information on health insurance. SSWs not wishing to complete this questionnaire were offered an abridged version (see online supplementary file) which was completed in the Fleur de Pavé bus straight away. As the Fleur de Pavé association provides services based on anonymity and freedom of access, we did not collect data concerning individuals entering the van but not staying long enough to be assessed for study eligibility (below).

Inclusion and exclusion criteria

Individuals (women, transvestites and transsexuals) of any age, offering paid sex in the street, working in the red light district of Lausanne, and able to give oral consent to take part in the questionnaire were included. Individuals unable to understand the questions in the questionnaire, those incapable of completing the questionnaire through being under the influence of alcohol or other substances, and those who had already completed the questionnaire were excluded.

Study questionnaires

The full questionnaire covered (1) socio-demographic and health status data: age, gender, country of origin, level of education, date of arrival in Switzerland (non-Swiss participants) and in Lausanne, possession of a residence permit (obligatory if resident in Switzerland for >90 days), possession of health insurance and the monthly cost of this, subjective health status, type of dwelling, ways of meeting clients other than on the streets, financial dependents in Switzerland or abroad, and hard and soft drug use and (2) data relating to access to and use of available healthcare facilities: whether participants were familiar with healthcare facilities in Lausanne (specifically, Lausanne Emergency Department (ED), the Department of Ambulatory Care and Community Medicine (DACCM), the hospital gynaecology service (HGS) and the Point d'Eau centre), whether they had experienced illness, injury or physical abuse in the preceding 12 months, centres visited for healthcare consultations, and whether the participants had disclosed their profession. Participants were also asked whether they had ever had an HIV test and, if so, when. Finally, participants were invited to provide reasons for not having health insurance, when applicable, and their perceived healthcare needs.

The abridged questionnaire covered age, gender, country of origin and possession of health insurance (see online supplementary file).

Data analysis

Data are presented as means with SD, medians with IQR or percentages. Categorical data were assessed in two-way contingency table analyses using χ2 tests. Analyses were performed using Microsoft Excel 2008 (Microsoft Corporation, Redmond, Washington, USA).

Results

Fleur de Pavé van attendance

Approximately 40 SSWs entered the van in the course of each 4-h period, some entering on more than one occasion. While some SSWs entered to use the facilities offered by the Fleur de Pavé staff, others came in to shelter from the cold, particularly in the winter months.

Questionnaire acceptance rate

Overall, 70 SSWs were approached in the van of whom two did not work in the streets and two did not have the capacity to consent to being interviewed (substance intoxication). Of the 66 who fulfilled inclusion criteria, 50/66 (76%) agreed to complete the full questionnaire (10/50 (20%) doing so in French). The other 16/66 declined for the reason of ‘lack of time’ but agreed to complete the abridged questionnaire.

Socio-demographic characteristics

Of 50 SSWs completing the full questionnaire, 48/50 (96%) were migrants, the majority from Brazil, Romania and West Africa. Age, gender and country of origin were similar between SSWs completing the full and those completing the abridged questionnaire (table 1). Fewer than half (22/50, 44%) had been educated beyond obligatory schooling level.

Table 1

Socio-demographic characteristics of SSWs in Lausanne who completed the full and the abridged questionnaires

Since arriving in Switzerland, the majority had remained in Lausanne. Excluding the two Swiss nationals, 33/48 (69%) of the migrant SSWs interviewed had no residence permit. Of these individuals, 10/33 (30%) had been resident in Switzerland for fewer than 90 days and were from countries not requiring a visa to enter the country (although still requiring a permit to work). Of these 10, 8 (80%) were from Romania, one from Portugal and one from Brazil.

Of all the participants interviewed, 28/50 (56%) had no health insurance. The main reason for not having health insurance was cost (17/28 (61%) of participants). Although only 5/28 (18%) stated having no residence permit as a reason for no health insurance, we observed that participants lacking such a permit were significantly less likely to possess health insurance: 16/17 (94%) participants who had a residence permit also had health insurance whereas 6/33 (18%) participants without a permit had insurance (p<0.0001). Of the 22 participants who did have health insurance, the median cost per month was CHF297 (IQR CHF200–346), equivalent to 245 Euros (IQR 165–286 Euros). In all, 17 of the 22 with health insurance (77%) were up to date with their monthly payments.

Almost half the participants (23/50, 46%) lived in their place of work. Almost a third worked in salons (16/50, 32%) in addition to the street. Most (36/50, 72%) had people dependent on their income, the majority of dependants living abroad (34/36, 94%).

Drug use and subjective health status

Five out of 50 participants (10%) had taken marijuana and/or cocaine in the preceding 6 months; no participant admitted to taking heroin/methadone or to injecting drugs. In the preceding week, 7/50 participants (14%) had taken hypnotics, antidepressants or anxiolytics.

When questioned about their subjective current health status, 15/50 (30%) described their health as ‘very good’, 17/50 (34%) as ‘good’, 15/50 (30%) as ‘average’, 2/50 (4%) as ‘poor’ and 1/50 (2%) as ‘very poor’.

Knowledge of healthcare facilities and patterns of consulting

Among the 50 participants questioned, 36/50 (72%) were aware of Lausanne ED, 17/50 (34%) knew of the DACCM, 25/50 (50%) knew of the HGS and 15/50 (30%) knew of the Point d'Eau. In the preceding year, 36/50 (72%) participants had been unwell, had an accident or been a victim of physical violence: 22/36 (60%), 3/36 (8%) and 18/36 (50%) cases, respectively. Of the 18 victims of violence, four (22%) had sought medical advice after the event. A total of 36 participants (36/50, 72%) had consulted a doctor in the preceding year, generating 54 consultations including 17 check-ups. Most consultations were related to primary healthcare (21/54 consultations (39%), including 6/54 (11%) for flu-like symptoms) and gynaecology (13/54 consultations (24%), including 1/54 (2%) for ectopic pregnancy). Lausanne ED (14/54, 26%), the HGS (11/54, 20%) and clinics abroad (11/54, 20%) were the services most used. Depending on the service consulted, participants disclosed their profession 40%–64% of the time (table 2). Professional disclosure was more frequent to HGS staff or healthcare professionals outside Switzerland but this difference was not significant (p=0.9). Only 3/36 participants stated they would not return to see a healthcare professional, for the following reasons: ‘not treated well’; ‘they [the healthcare providers] did nothing, just looked’ and ‘poor treatment of immigrants’.

Table 2

Awareness and use of available healthcare facilities by SSWs in Lausanne and disclosure of profession to healthcare professionals consulted

A total of 35 out of 50 participants (70%) were unaware of the Point d'Eau centre. Of these, 6/35 (17%) consulted outside Switzerland, 5/35 (14%) visited the DACCM and 11/35 (31%) presented to Lausanne ED; 8/35 (23%) had not seen a healthcare professional in the past year. No participant gave ‘no health insurance’ as a reason for not consulting (data not shown).

Overall, 42 out of 50 participants (84%) believed it necessary to create specialised medical services for SSWs in Lausanne, with gynaecology, primary health, dental and psychiatry services being the top four suggestions (table 3).

Table 3

Perceived healthcare needs among SSWs in Lausanne

HIV testing history

Excluding two participants who volunteered having HIV, 24/48 (50%) had previously been tested, of whom 12/48 (25%) had been tested in the preceding year. Of the six participants consulting a doctor for flu-like symptoms mentioned above, one had been tested in the preceding year and two had never been tested. The participant seen for ectopic pregnancy had last been tested 4 years previously.

Discussion

In our sample of 50 SSWs, 48/50 (96%) were migrants of whom 33/48 (69%) had no residence permit. While the median time of residence in Switzerland was 2.1 years, 10/48 migrants (21%) had been resident for <90 days. Fewer than half (22/50, 44%) had been educated beyond obligatory schooling level and 22/50 (44%) possessed health insurance. Awareness of healthcare facilities beyond EDs and the HGS was low.

One previous study on SSWs is comparable with ours in terms of the mode of recruitment and type of survey conducted. Jeal and Salisbury approached and interviewed 71 SSWs in Bristol, UK, via a charity which supports SSWs and an outreach van operated by this charity.1 ,3 The sample size and mean age (27.9 years) of the Bristol SSWs were comparable with those of our study. However, 87% of the Bristol group were Caucasian, all reported chronic health problems, all had current or recent drug or alcohol dependency problems and 60% injected drugs.3 The most common source of healthcare for the Bristol group was a general practitioner (used by 58% of respondents),1 likely reflecting the different healthcare systems in Bristol and Lausanne: a national health service providing free healthcare at the point of delivery in Bristol compared with a private insurance-based system in Lausanne. Of SSWs registered with a general practitioner, 62% had not disclosed their profession.1 In the preceding year, 46% of the Bristol SSWs had been screened for sexually transmitted infections and 18% had never been screened; screening specifically for HIV was not reported by the authors. Finally, the perceived healthcare requirements differed between the Bristol and Lausanne groups, with the Bristol SSWs prioritising condom distribution, needle exchange and a facility near their place of work with evening/night opening, services provided in the Lausanne Fleur de Pavé van.

Our study has several limitations. First, it is surprising that 32/50 (64%) of participants described their health status as ‘good’ or ‘very good’, given the findings of Jeal and Salisbury, above1 ,3. It is possible that our health status classification was interpreted as physical, as opposed to mental, health and thus we may have underestimated the burden of mental health observed elsewhere in Switzerland.12 We may also have underestimated poor health by recruiting SSWs only from a van situated in the designated red light district; we did not reach SSWs who practise illegally, that is, outside the designated zone, who may have poorer health or a history of drug dependence. That said, while it is possible to sell sex outside the designated zone, it is difficult to do so on the street, as opposed to in salons or bars, owing to widespread police checks (AA-P, personal communication). Second, we did not ask about anticipated time to remain in Switzerland. It is possible that SSWs from Romania, for example, stay only for the 90 days permitted for nationals of new European Union countries: eight of the nine SSWs from Romania (89%) had been in Switzerland for less than this time. If this is the case, there would be a potential turnover of a fifth (21%) of the Lausanne SSW population every 3 months. Without longitudinal data, it is difficult to examine the extent of mobility among Lausanne SSWs and to fully anticipate healthcare needs. That said, the issues of education level, language barriers and knowledge of healthcare facilities have an impact on this migrant population whatever the rate of mobility. Finally, owing to the high turnover of SSWs in the Fleur de Pavé van, together with the anonymous and free-access approach of the Fleur de Pavé association, it was not possible to obtain a denominator against the 70 SSWs we approached. Without having a defined denominator population, it is not possible to state that the SSWs we report are fully representative of all SSWs in Lausanne. Against these limitations, the uptake rate among SSWs approached was high, with all individuals fulfilling inclusion criteria agreeing to complete either the full or the abridged questionnaire. Demographic profiles from both questionnaire groups (full and abridged) were similar, suggesting that the demography of the population we analysed (the 50 SSWs completing the full questionnaire) was representative at least of SSWs who use the Fleur de Pavé van.

The data from our study highlight two main concerns. The first concern is that of healthcare provision for our SSW population. Fewer than a third of participants were aware of the Point d'Eau service, where primary healthcare and gynaecology services are provided free of charge regardless of residence and insurance status, when these two services were those most commonly used during the preceding 12 months, and most commonly stated as needed (31/42 participants, 74%). Participants unaware of this free service saw healthcare professionals abroad or attended hospital EDs for problems that were not necessarily ‘emergencies’. This lack of awareness is in keeping with the linguistic and educational profiles of this heterogeneous migrant population. It would seem that, prior to, or at least in tandem with, expanding available healthcare services, measures are required to disseminate information on these. It is interesting that ‘no health insurance’ was not given as a reason for not consulting a healthcare professional, suggesting that lack of insurance is a less important barrier to accessing healthcare than lack of awareness of available facilities.

The second concern is that of SSW well-being with implications for public health as a whole. Figures from cross-sectional surveys from 1987 to 2000 in Switzerland showed that almost one in six men aged 17–45 years had visited a sex worker.13 Our group recently observed that 6%–11% of clients of female sex workers in Lausanne's red light district have practised unprotected commercial sex.14 Around Lausanne, HIV prevalence is estimated to be 0.4% and, while there are no official figures, it is likely that the prevalence among SSWs (2/50 (4%) in this survey) is higher: although injecting drug use was not volunteered as a risk factor, 15/66 participants questioned on country of origin (23%) came from sub-Saharan Africa. It is concerning that, among seven SSWs with clinical presentations (flu-like symptoms/ectopic pregnancy) in which HIV testing should have been proposed given the high-risk context,15 only one individual had been tested for HIV in the past year. While not a barrier to healthcare access, the high rate of profession non-disclosure we observed may present a barrier to appropriate and targeted delivery of healthcare.

In summary, we observe that, whether through mobility, lack of education or social isolation, SSWs in Lausanne lack awareness of free healthcare services provided to those without residence permits or health insurance. The inappropriate use of other healthcare resources may result in suboptimal quality and continuity of care, this in turn having potential consequences for both individual well-being and public health. Our results suggest that, in addition to receiving psychosocial support and material promoting HIV prevention, this vulnerable population would benefit from improved dissemination of information regarding centres where primary healthcare services can be accessed, if need be, free of charge. Finally, the absence of HIV testing among half the SSWs interviewed deserves public health attention.

Main messages

  • Street-based sex workers (SSWs) in Lausanne, Switzerland, represent a heterogeneous, mobile and vulnerable group: 96% are migrants and 56% have no health insurance.

  • Most SSWs (70%) are unaware of available healthcare services, resulting in inappropriate use of emergency services. SSWs did not disclose their profession when seeking healthcare in as many as 60% of visits.

  • HIV prevalence in this group, as ascertained from our questionnaire, was 2/50 (4%); only 12/48 (25%) of SSWs not known to be HIV positive had been HIV tested within the preceding year.

  • Lack of HIV screening in this at-risk group merits attention from both individual and public health perspectives.

Current research questions

  • To determine the socio-demographic characteristics of Lausanne's SSWs, a group hitherto poorly characterised.

  • To examine factors which may affect access to healthcare in this population, specifically, awareness of available healthcare facilities.

  • To explore the patterns of healthcare facility utilisation compared with the subjective healthcare needs of this population, and to examine HIV testing history.

Key references

  • Jeal N, Salisbury C. Self-reported experiences of health services among female street-based prostitutes: a cross-sectional survey. Br J Gen Pract 2004;54:515–19.

  • Jeal N, Salisbury C, Turner K. The multiplicity and interdependency of factors influencing the health of street-based sex workers: a qualitative study. Sex Transm Infect 2008;84:381–5.

  • Vandepitte J, Lyerla R, Dallabetta G, et al. Estimates of the number of female sex workers in different regions of the world. Sex Transm Infect 2006;82(Suppl 3): iii18–25.

  • Jeannin A, Rousson V, Meystre-Agustoni G, et al. Patterns of sex work contact among men in the general population of Switzerland, 1987–2000. Sex Transm Infect 2008;84:556–9.

  • Darling KE, Diserens EA, Nâ Garambe C, et al. A cross-sectional survey of attitudes to HIV risk and rapid HIV testing among clients of sex workers in Switzerland. Sex Transm Infect 2012;88:462–4.

Acknowledgments

We thank Dr Giovanna Meystre-Agustoni at the Institute of Social and Preventative Medicine, Lausanne, Switzerland, who assisted EG in designing and creating the questionnaire, and the interviewers of the Fleur de Pavé association, for their active participation.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

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Footnotes

  • KEAD, EG, PB and MC contributed equally

  • Contributors Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data: KD, EG, AA-P, PV, PB, MC. Drafting the article or revising it critically for important intellectual content: KD, EG, PB, MC, SD-P. Final approval of the version to be published: KD, EG, AA-P, PV, SD-P, PB, MC.

  • Funding This study was funded by the Faculty of Biology and Medicine of the University of Lausanne, Switzerland. The funders had no role in designing the study, collecting, analysing or interpreting the data, or in drafting this manuscript.

  • Competing interests None. All authors, external and internal, had full access to all of the data in this study and can take responsibility for the integrity of that data, and the accuracy of the data analysis.

  • Ethics approval Protocol 13/10, obtained 29 January 2010.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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