# Vulnerability and psychological distress of female sex workers in Côte d'Ivoire

Hasna Youssoufa, Marcelin N'Zebo Nouaman, Charlotte Bernard, Valentine Becquet, Patrick Coffie, Aline Agoua, Serge Eholié, Joseph Larmarange, Mélanie Plazy

► To cite this version:

Hasna Youssoufa, Marcelin N'Zebo Nouaman, Charlotte Bernard, Valentine Becquet, Patrick Coffie, et al.. Vulnerability and psychological distress of female sex workers in Côte d'Ivoire. AIDS 2024, the 25th International AIDS Conference, Jul 2024, Munich, Germany. . [hal-04660379](https://hal.science/hal-04660379v1)

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Submitted on 23 Jul 2024

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# Vulnerabilities and psychological distress among female sex workers in San Pedro, Côte d'Ivoire

H. Youssoufa ¹, M. Nouaman ²,³, C. Bernard ¹, V. Becquet ⁴,⁵, P.A. Coffie ²,⁶, A. Agoua ⁷, S. Eholie ²,⁶, J. Larmarange ⁵,⁴, M. Plazy ¹

1. Bordeaux Population Health Research Center, Université de Bordeaux, Inserm UMR 1219, IRD EMR 271 - Bordeaux (France), 2. PAC-CI - Abidjan (Côte d'Ivoire), 3. Département de Santé Publique, UFR d'Odonto-Stomatologie, Université Félix Houphouët-Boigny - Abidjan (Côte d'Ivoire), 4. Ined - Paris (France), 5. Ceped, Université Paris Cité, IRD, Inserm - Paris (France), 6. ONG Aprosam - San-Pédro (Côte d'Ivoire), 7. Département de Dermatologie et Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët-Boigny - Abidjan (Côte d'Ivoire).

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## Context

* Female sex workers (FSW) are exposed to several vulnerabilities at the individual, family/community and structural levels.

* These vulnerabilities constitute multiple factors that can increase mental health, such as depressive disorders and anxiety disorders.

* There is very little literature regarding mental health among FSW, especially in West Africa.

* The WHO called, in 2022, for more mental health research in order to inform policymakers.

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## Objective

To describe vulnerabilities and psychological distress among FSW included in a sexual and reproductive health cohort in Côte d'Ivoire, and identify key factors associated with psychological distress.

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## Study setting

### San Pedro region in Côte d'Ivoire

* Region with farming businesses (coffee, cocoa, palm oil and hevea)

* One of the most important harbours in West Africa

* HIV incidence among FSW estimated to be 3.3% in 2016-2017 (Nouaman et al, 2022).

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### The ANRS 12381 PRINCESSE cohort

**Objective:** to implement and evaluate a comprehensive and community-based sexual and reproductive health care package for FSW ≥18 years old.

**Study design:** single-arm interventional cohort (Nov 2019 - Jul 2023).

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## Methods

**Study population:** FSW who completed at least one socio-behavioural questionnaire, without missing data regarding psychological distress.

**Main outcome:** Psychological distress of FSWs, assessed using the 4-item Patient Health Questionnaire (PHQ-4) scale (Kroenke et al, 2009) composed of four questions:

- the two first items screening anxiety's symptoms ("Feeling nervous, anxious or on edge" and "Not being able to stop or control worrying")

- the two last items screening depression's symptoms ("Feeling down, depressed or hopeless" and "Little interest or pleasure in doing things").

Each item had four answers: "not at all" (score 0), "several days" (score 1), "more than half the days" (score 3) and "nearly every day" (score 4).

The total score of each participant was summed up and classified according to the level of psychological distress: normal (total score = 0-2), mild (3-5), moderate (6-8), severe (9-12).

**Statistical analysis:** Logistic regression assesses the association between having at least mild psychological distress and socio-demographic characteristics as well as vulnerability variables.

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## Population selection

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## Conclusion

FSWs face several vulnerabilities, which are associated with signs of psychological distress. Those who were isolated, precarious, living with HIV, and/or experiencing violence were the most vulnerable to developing signs of psychological distress.

→ These results underline the need to consider how to integrate mental health issues into sexual health programs for FSW.

**Strengths:** it is one of the first mental health studies about FSW in West Africa.

**Limitations:** FSW included in this analysis were not representative of all the FSW of the PRINCESSE project nor of all the FSW in Côte d'Ivoire, leading to a selection bias. In addition, there is a risk of social desirability bias that could have underestimated the proportion of psychological distress.

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## Socio-demographic characteristics, sex work conditions and vulnerabilities

### Socio-demographic characteristics

* 21% ≤ 24 years old and 13% ≥ 40 years old

* 33% never been to school

* 48% Ivorian

* 15% in couple with cohabitation and 38% in couple without cohabitation

* 13% HIV-positive

### Sex work conditions

* 74% sex work as a main activity

* 40% worked as FSW for less than 1 year, 30% for more than 5 years

* 60% worked in a brothel, and 73% worked almost everyday

* 32% had already had sex with a client under the influence of alcohol

### Economic vulnerability

* 54% perceived their financial status as very difficult

### Social vulnerabilities

* 11% experienced violence from their regular partner

* 18% experienced violence from friends or family members

* 9% declared poor emotional support

* 13% had a very low self-esteem

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Photo:
V. Becquet

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## Level of psychological distress

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## Vulnerabilities and other factors associated with psychological distress

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Ceped
UMR 196

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Université
Paris Cité

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Institut de Recherche
pour le Développement
FRANCE

ined

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D'ÉTudes DÉMOGRAPHIQUES

BORDEAUX
POPULATION
HEALTH

Cité de
Recherche
U1210

université
de
BORDEAUX

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anrs
MALADIES INFECTIEUSES Inserm

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